| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.18(c) | Individual #1's house an agency incident reporting form was found. The form was completed on 1/23/18 and it indicated that individual #1 and another individual not supported by QLS bit each other and it indicated a check mark next to if an incident was filed. There is no incident filed for this individual to individual to individual incident. There is also no record of this incident being a consensual act between the two individuals. | The home shall orally notify the county intellectual disability program of the county in which the home is located, the funding agency and the appropriate regional office of intellectual disability, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs.
| This is important because all incidents need to be reported to management to ensure that proper procedures are followed and if necessary an investigation submitted.
An Accident/Illness/ Injury form was found at an individual¿s home indicating that the individual was bitten by another individual and the form indicated that an incident report was filed, however, there was no incident report filled in EIM.
The incident report was turned into management but once the Program Specialist had inquired about the bit it was determined to be a consensual act. Nevertheless, the Program Manager failed to document their knowledge.
Upon the completion of the exit interview with the licensers the Program Specialist obtained the form from the house. The form was a copy of an Accident/Illness/Injury Report that was submitted to the office regarding a sucker bite type mark that two individuals had given each other while they were experiencing personal time together. This copy of the form was to be filed in the individuals file at the home but never was. The Program Specialist had met with both individuals on September 13, 2018 and had obtain statements from them that this act was consensual. This process also took place at the time the Accident/Illness/Injury report was reviewed by the Program Specialist, but written verification wasn¿t obtained at that time. Due to this being a consensual act there was no need for an incident report to be filed. The verification statements are being forwarded to you at this time as Attachment #34 & #35.
On September 18, 2018, management has since been re-trained on the importance of documentation, especially when the act could be viewed as a potential reportable incident. Any future events, where a reportable incident is reported to management, and determined to not fall within the reportable incident guidelines, that report shall be placed inside the individual¿s incident file, along with any documentation collected to disprove its reportability. |
09/18/2018
| Implemented |
| 6400.22(d)(2) | Individual #1's august 2018 financial log indicated the ending balance was $5.85. However, the September 2018 starting balance was $3.63 with no indicated where the extra money went. Then the ending September 2018 financial log located at the home indicated $.68 should be at the house. However, staff counted wrong and the balance should have been $3.68 for the end of September 2018 so far. There was only $.68 at the home with no indication where the missing money is. | (2) Disbursements made to or for the individual.
| It is important to ensure that the individual¿s funds are always accounted for.
There was a lack of documentation regarding funds spent on behalf of or for the individual.
Staff improperly documented the expense incurred by the individual, in this case a tip that was given by the individual to a waitress.
There was an Incident filed on September 13,2018 for Misuse of Individual Funds; Incident #846922 and an investigation was conducted. The individual¿s funds were also audited on September 13, 2018 and the monies were adjusted to the proper audited balance.
on September 25, 2018 we established a system that at midnight every night we have certain documents faxed to the office for review by management members. The individual¿s funds are one of the forms that are forwarded to the office as well as an audit of their monies. This allows the monies to be audited more frequently. The form that is being utilized to audit the individual¿s monies on hand is being forwarded to you as Attachment #8. Also, as the Field Manager is performing his inspections of the homes he is also responsible for checking the individual¿s funds register and their cash on hand to ensure compliance. Please see Attachment #2 for the Field Managers inspection sheet. Furthermore, the importance of keeping accurate documentation when dealing with consumer funds will be discussed on October 25, 2018, to all direct care staff. |
09/25/2018
| Implemented |
| 6400.44(b)(7) | The program specialist did not report the content discrepancy around individual #1 supervision levels. His assessment indicated "nick needs 24-hour awake staff in his home. he has 1:2 staffing during awake and sleeping hours. nick can be without direct supervision while in his home. he has alone time in the bathroom and his bedroom. staff need to be aware of nick's whereabouts while in his home. staff is with his at all times while in the community." His ISP indicated "home supervision staff ratio 1:2 and community supervision nick is never left alone in the community. Supervision ratio is 1:2." Multiple times the program specialist sent emails to the supports coordinator throughout the year indicating that no changes need made to his ISP. However, his supervision needed updated. (see 213(11) for the dates of emails sent indicating no changes needed to ISP) | The program specialist shall be responsible for the following: Reporting content discrepancy to the SC, as applicable, and plan team members. | To be able to ensure the proper Health and Safety of the individuals that we support at QLS it is imperative that the individual¿s records are free from content discrepancy.
The Program Specialist failed to ensure the accuracy between the ISP and Assessment for Individual #1.
The Program Specialist indicated via email that no updates or changes were required to the individual¿s ISP.
The discrepancies were immediately addressed through the review of documents by the individual¿s team which has been either immediately corrected if possible or is currently in the process of being corrected as some of these issues were being addressed within a POC from an unannounced licensing on July 31, 2018.
QLS was in the process of modifying and updating individual care needs and getting them approved by all team members before their implementation. As of October 1, 2018, all supervision care need plans have been submitted to the individual¿s SC and are awaiting implementation.
QLS is in the process of transferring our individual information to a database system that is going to automatically transfer most of their vital information to the associated forms so this data is only being managed in one centralized location and then fed to the appropriate documents so there is no more oversight of data or inaccurate data between documents which would include physicals, assessment, medical histories and ISP reviews. Each individual will have their information loaded into the database by November 1, 2018 and then the associated forms will be generated using this platform as they become due. Once the vital information is loaded and confirmed by the individual¿s team, the operations department would deny access to this vital information sheet acting as its supervisor for any additional changes or modifications. As of November 1, 2018, all QLS managers will be trained on the use and production of this database which will be ensured by the operations department.
We have also developed an ISP Review Checklist that we were in the process of implementing at the time of the current licensing. This ISP Review Checklist had an implementation date of October 1, 2018 in which we were utilizing to check the current approved ISP¿s from HCSIS system and then by November 1, 2018 every individual¿s ISP will be reviewed using this form. A copy of the utilized form is attached as Attachment #6. This checklist is being utilized by the following departments; Medical, Program and Behavioral Supports to ensure that the content of the ISP that their department oversees is correct and up to date. |
10/01/2018
| Implemented |
| 6400.67(a) | 249 3rd Ave, Hastings pa home had a piece of ceiling trim located in the upstairs bathroom tub ceiling, was peeling away from the wall. | Floors, walls, ceilings and other surfaces shall be in good repair. | It is important to ensure the individuals home is in good repair.
Individual #1¿s ceiling trim in the bathroom peeled away from the wall.
This occurred from every day use and staff failing to write up the issue.
We had the ceiling trim repaired on September 17, 2018 and Attachment #33 is a picture of the repaired area.
The Field Manager and Maintenance Department have been provided Maintenance Repair Orders that they are to complete while out in the field. It was always prior practice that when they were in the home and seen an item that needed repaired that they would have the direct care staff write it up. Moving forward they will write the issues that they notice during home inspections themselves. The Operations Manager will inspect the homes periodically multiple times a year to make sure that the homes are being maintained in good condition. The operations department will document each home inspection with an already existing house inspection form. During the companywide meeting on October 25, 2018 it will be reviewed with all direct care staff the expectations of a maintaining home in good repair. |
09/17/2018
| Implemented |
| 6400.112(c) | The staff is not checked each smoke detector for operability every month at 249 3rd Ave Hastings, pa. The staff is only setting off one smoke detector and listening for the interconnected alarms to sound. The staff is not setting off each interconnected smoke detector. There are multiple other smoke detectors throughout the home, not on the interconnected system, that aren't being checked at all. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | This is important because QLS wants to ensure the safety and well being of the individuals in the case of an emergency.
QLS direct care staff was not checking all smoke detectors for operability.
Staff failed to properly answer the questions on the written fire drill form.
As of October 25, 2018, at a company meeting, all staff have been made aware of the need to check all fire alarms.
We reviewed our form regarding compliance in this area and it was determined that the form lacked detail when it came to the area of distinguishing interconnect alarms vs. non-interconnect alarms. Our Fire Drill Form was updated to contain 2 questions. It now specifies to check all alarms whether they are interconnected or non-interconnected. These fire drill forms are generated by the Program Specialist and will be utilized companywide moving forward as fire drills are being conducted. The Fire Drill Form is reviewed by the Operations department upon its completion by the residential staff. |
10/25/2018
| Implemented |
| 6400.142(d) | According to individual #1's 9/11/17 dental appointment form, he was seen by dentist for an "6-month cleaning" and was to return in 6 months. There is no other documentation in their record to indicate another cleaning occurred. All other dental records in individual #1's record, 11/6/17, 11/30/17, 1/11/18, 3/14/18, and 5/1/18 appointment summary forms, only indicated fillings were completed. | The dental examination shall include teeth cleaning or checking gums and dentures. | It is important to ensure that the individuals at QLS maintain their dental hygiene.
Staff failed to acknowledge that a cleaning of the individual¿s teeth had occurred within the 6-month time requirement.
Staff failed to fill out the Medical/Dental Appointment form correctly.
Management contacted the individual¿s dentist and it was confirmed that he did have a cleaning performed on March 14, 2018. Attached as Attachment #32 is an Account History Report that details the services that were performed on March 14, 2018 on behalf of Individual #1.
The current Medical/Dental Appointment form has been revised to replace the wording of Prophy with Cleaning. The new form has been distributed to the homes effective October 11, 2018 and the staff members have been directed to utilize the new form going forward and were asked to please dispose of the prior forms. Attachment #31 is the revised Medical/Dental Appointment Form. The importance of filling out the form correctly will be expressed at the company wide meeting on October 25, 2018. Our Program Specialist will track the dental appointments and provide the Medical Coordinator with a list of needed upcoming appointments. The Medical Coordinator ensures that the appointments are scheduled in a timely manner and then upon completion of the appointment the Program Specialist updates the tracking for compliance. The current tracking system is generating data to ensure that the individual is seen every 6 months for routine dental cleaning |
10/11/2018
| Implemented |
| 6400.144 | Individual #1 was seen on 9/11/17 by his dentist and was to return on 10/9/17 for fillings. He did not return for fillings until 11/6/17.
-individual #1 was seen on 11/30/17 by his dentist and was to return on 12/27/17 for fillings. He did not return for fillings until 1/11/18.
-individual #1 was seen on 3/14/18 by his dentist and was to return on 4/9/18 for fillings. He did not return for fillings until 5/1/18. | 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.
| It is important for QLS to ensure the health, safety and wellbeing of all its individuals.
QLS failed to ensure individual #1¿s medical needs were being met.
At the time of this appointment, QLS had an unlicensed person providing for the medical coordination of the individuals QLS supports.
QLS attempted to find the reasoning behind the individual missing his appointments and found that the individual was on a home visit for the appointment scheduled on 12/27/17 and requested that the appointment be rescheduled. QLS could not ascertain a reasoning through documentation or direct care staff as to why the other appointments were rescheduled. Nevertheless, Program Specialist has made attempts to educate the individual on the importance of keeping dental and doctor appointments.
On September 17, 2018, we filled our Medical Coordinator position with an LPN. This individual has an extensive background in home health and understands the importance of detailed documentation as well as the proper procedure when making notations on already completed documents.
The Medical Coordinator is now attending the Behavior Supports meetings that are held with Direct Care Staff to review any health concerns or questions that the staff may have as well as to provide them education on symptoms or a diagnosis. Attachment # 38 is the minutes from a BSP Meeting that was held on September 20, 2018, in which the Medical Coordinator attended and provided education about the individuals ADA Diet. She also provided staff information to help assist staff in planning a menu. |
09/17/2018
| Implemented |
| 6400.164(a) | Staff #2 signed as administering individual #1 ibuprofen 600mg on 9/6/17 however did not record am or pm. Staff #1 recorded "3:24" on the front of the medication log and "3:24" under time given on the back of the medication log. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | It is important to able to know what time, date and dosage of the medications that are being administered so that the agency can determine the amount of time between administrations, how much was administered, and what day they were administered.
Staff failed to indicate AM or PM on the MAR.
It was an oversight on staff #1¿s part.
Attachment #1 is an agency wide memo that was sent out on September 17, 2018, reminding staff that any time a PRN Medication is dispensed that it must include the reference of either AM/PM.
On September 25, 2018 we established a system that at midnight every night we have certain documents faxed to the office for review by management members. The MARS in their entirety are one of the documents that are forwarded to the office. This allows management to review the MARS daily ensuring that the proper documentation is noted. |
09/17/2018
| Implemented |
| 6400.168(d) | Staff #1 medication training date needs to stay the same. Currently he had pass dates of 8/8/17 and 8/9/18; late. Use 8/9 as annual date moving forward due to it being late. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | This is important to ensure that QLS staff is adequately trained on administering medication.
Management improperly tracked medication training.
Management believed that the Annual date never changed from the date of the first medication administration training.
We have since updated our training tracking system to reflect the last recertification date for each employee rather than their annual training date.
The medication instructors have been educated on how the form is expected to be utilized. The operations department shall oversee the accuracy of this tracking upon its annual completion. Attached as Attachment #30 is a recently completed medication observation showing the forms being utilized as expected. |
09/18/2018
| Implemented |
| 6400.181(e)(5) | Individual #1 12/8/17 assessment does not indicate his ability to take medications. His assessment only indicated, "Individual #1 does not take medications on a daily basis. he was prescribed a daily medication in the past, but no longer takes it. staff will administer any medications that he may need." | The assessment must include the following information: The individual's ability to self-administer medications. | It is important to ensure that documentation exists regarding his ability to self-administer medication if he is ever prescribed medication.
The individual¿s assessment lacked information regarding his ability to self-administer medication.
QLS has never supported an individual that wasn¿t medicated and was unaware that this information needed to still be contained within the Assessment.
The Program Specialist prepared an Addendum for this portion of the Assessment and it is attached as Attachment #29. This was also discussed and educated on in the management meeting held on September 18, 2018.
As we were building the database system and we included a notice in this section to remind the author of the document that this information needs to be contained within this section even if the individual is not currently medicated. Each individual will have their information loaded into the database by November 1, 2018 and then the associated forms will be generated using this platform as they become due. Effective November 1, 2018, the Assessment will be reviewed and signed off by the Medical Coordinator as a double check is to ensure that all health services referred to in the Assessment are being implemented as written. As of November 1, 2018, all QLS managers will be trained on the use and production of this database which will be ensured by the operations department. The revised Assessment format is attached for your review as Attachment #13 |
09/18/2018
| Implemented |
| 6400.181(e)(12) | Repeat from 8/16/17: Individual #1's 12/8/17 assessment does not contain recommendations to specific areas of training, programming and services. His assessment simply indicated that he does not require additional services, doesn't attend programming and isn't interested, and he's working with OVR job coaching. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | It is important to document what recommendations the Program Specialist may have for the individual.
The assessment failed to be specific on training, programing, and services.
The Program Specialist was not adequately documenting recommendations required under the regulation.
The Program Specialist prepared an Addendum for this portion of the Assessment and it is attached as Attachment #29. At a management meeting held on September 18, 2018, the importance in providing this information was discussed and elaborated upon.
In the database system we incorporated more detailed headings for this section of the assessment that will remind the author to expand the areas of training, programming and services that were offered/recommended to the individual. Each individual will have their information loaded into the database by November 1, 2018 and then the associated forms will be generated using this platform as they become due. Effective November 1, 2018, the Assessment will be reviewed and signed off by the Medical Coordinator as a double check is to ensure that all health services referred to in the Assessment are being implemented as written. As of November 1, 2018, all QLS managers will be trained on the use and production of this database which will be ensured by the operations department. The revised Assessment format is attached for your review as Attachment #13. |
09/18/2018
| Implemented |
| 6400.181(e)(13)(ii) | Repeat from 8/16/17: Individual #1's 12/8/17 assessment does not contain his progress and growth in the areas of motor and communication skills. There was only a current level of skills recorded in this area. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | It is important to document the individuals progress and growth to be able to determine how they are functioning while in the care of QLS.
The assessment failed to be specific on the individuals progress or growth.
The Program Specialist was not adequately documenting the individual¿s progress and growth.
The Program Specialist prepared an Addendum for this portion of the Assessment and it is attached as Attachment #29. At a management meeting held on September 18, 2018, the importance in providing this information was discussed and elaborated upon.
The Assessment is one of the forms that was transferred to the database system therefore that will be the only Assessment available to the Program Specialists. The Assessment format that was developed into the database system contains all the components that this regulation requires, therefore the Program Specialist will have all necessary components in each completed Assessment. Furthermore, on the database system the format of the document is unable to be altered by the user so there will not be the opportunity for something to be deleted in error.
Effective November 1, 2018, the Assessment will be reviewed and signed off by the Medical Coordinator as a double check to ensure that all health services referred to in the Assessment are being implemented as written. As of November 1, 2018, all QLS managers will be trained on the use and production of this database which will be ensured by the operations department. The revised Assessment format is attached for your review as Attachment #13. |
09/18/2018
| Implemented |
| 6400.181(f) | Repeat from 8/16/17: Individual #1's 12/8/17 assessment did not indicate who it was sent to. It had the word "sent" written above "family/guardian", "supports coordinator" and "behavior specialist." The assessment did not indicate that their received a copy of his assessment. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| It is important for QLS to document the exact team members, by name, because their support team often changes.
QLS failed to name who the assessment was sent to.
Although it indicated that assessment was sent, it did not specifically name who it was sent to.
Program Specialist were educated by the Operations Manager, during management held on September 18, 2018, the importance to include specific names of who the information is being sent.
QLS is in the process of transferring our individual information to a database system that is going to automatically transfer most of their vital information to the associated forms so this data is only being managed in one centralized location and then fed to the appropriate documents so there is no more oversight of data or inaccurate data between documents which would include physicals, assessment, medical histories and ISP reviews. Each individual will have their information loaded into the database by November 1, 2018 and then the associated forms will be generated using this platform as they become due. Once the vital information is loaded and confirmed by the individual¿s team, the operations department would deny access to this vital information sheet acting as its supervisor for any additional changes or modifications. As of November 1, 2018, all QLS managers will be trained on the use and production of this database which will be ensured by the operations department. Attached as Attachment #13 is a copy of a completed Assessment that specifically names each team member that was notified. |
09/18/2018
| Implemented |
| 6400.183(7)(iii) | Individual #1's ISP didn't include potential to advance in vocational programming. ISP just said he's not interested. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. | It is imperative for QLS to be able to document and understand the individual¿s potential to advance with a trade or any form of vocational programming so that the individual may advance or grow while in the care of QLS.
The Program Specialist was not detailed in describing the individual¿s potential to advance in vocational programming.
The Program Specialist who was responsible for this individual failed to provide or obtain adequate information regarding the individuals potential.
Through document review, the Program Specialist compiled information regarding which individual¿s ISP lacked this information. Emails were generated to the SC¿s prompting them to update the individual¿s ISP with the information provided. As of October 1, 2018, all management was trained and is utilizing the ISP review checklist.
We were in the process of implementing our ISP checklist at the time of the current licensing. This ISP Review Checklist had an implementation date of October 1, 2018 and on October 10, 2018 revisions were made to this checklist to include the items from Section 183(7) of the Regulations. We are going to continue to utilize the checklist to review the current approved ISP¿s from the HCSIS system and then by November 1, 2018 every individual¿s ISP will be reviewed using this form. A copy of the utilized form is attached as Attachment #6. This checklist is being utilized by the following departments; Medical, Program and Behavioral Supports to ensure that the content of the ISP that their department oversees is correct and up to date. The Program Specialist will be responsible to review the entire checklist once it has been reviewed and approved by the departments providing the information for each section. Once completed, The Program Specialist will prepare an email to the Supports Coordinator asking for the ISP to be updated to show the individuals potential to advance in vocational programming. That email is attached for your review as Attachment #28. |
10/01/2018
| Implemented |
| 6400.183(7)(iv) | Individual #1's ISP didn't include potential to advance in competitive community integrated employment programming. ISP just said he's not interested. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment.
| It is imperative for QLS to be able to document and understand the individual¿s potential to advance with competitive community-integrated employment so that the individual may advance or grow while in the care of QLS.
The Program Specialist was not detailed in describing the individual¿s potential to advance in competitive employment.
Individual #1 was a new admission and was only served by QLS for a short time. The Program Specialist who was responsible for this individual failed to provide or obtain adequate information regarding the individuals potential.
Through document review, the Program Specialist compiled information regarding which individual¿s ISP lacked this information. Emails were generated to the SC¿s prompting them to update the individual¿s ISP with the information provided. As of October 1, 2018, all management was trained and is utilizing the ISP review checklist.
We were in the processing of implementing our ISP checklist at the time of the current licensing. This ISP Review Checklist had an implementation date of October 1, 2018 and on October 10, 2018 revisions were made to this checklist to include the items from Section 183(7) of the Regulations. We are going to continue to utilize the checklist to review the current approved ISP¿s from the HCSIS system and then by November 1, 2018 every individual¿s ISP will be reviewed using this form. A copy of the utilized form is attached as Attachment #6. This checklist is being utilized by the following departments; Medical, Program and Behavioral Supports to ensure that the content of the ISP that their department oversees is correct and up to date. The Program Specialist will be responsible to review the entire checklist once it has been reviewed and approved by the departments providing the information for each section. Once completed, The Program Specialist will prepare an email to the Supports Coordinator asking for the ISP to be updated to show the individuals potential to advance in competitive community-integrated employment. That email is attached for your review as Attachment #28. |
10/01/2018
| Implemented |
| 6400.186(d) | Individual #1's 6/18/18, 3/14/18, 12/14/17, 9/13/17 ISP reviews didn't indicate who it went to for family/guardian or supports coordinator. No names were indicated on the ISP review form. Behavior support indicated n/a. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | It is important for QLS to document the exact team members, by name, because their support team often changes.
QLS failed to name who the ISP review was sent to.
Although it indicated that ISP review was sent, it did not specifically name who it was sent to.
Program Specialist were educated by the Operations Manager, during management meeting held on September 18, 2018, of the importance to include specific names of who the information is being sent.
QLS is in the process of transferring our individual information to a database system that is going to automatically transfer most of their vital information to the associated forms so this data is only being managed in one centralized location and then fed to the appropriate documents so there is no more oversight of data or inaccurate data between documents which would include physicals, assessment, medical histories and ISP reviews. Each individual will have their information loaded into the database by November 1, 2018 and then the associated forms will be generated using this platform as they become due. Once the vital information is loaded and confirmed by the individual¿s team, the operations department will deny access to this vital information sheet acting as its supervisor for any additional changes or modifications. As of November 1, 2018, all QLS managers will be trained on the use and production of this database which will be ensured by the operations department. Attached as Attachment #10 is a copy of a completed Quarterly Review that specifically names each team member that was notified. |
09/18/2018
| Implemented |
| 6400.186(e) | Individual #1's father and step-mother did not receive the option to decline his ISP review documentation until 1/9/18. Individual #1 has had ISP reviews completed before 1/9/18. There was no documentation that the behavior specialist was offered the option to decline his ISP review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | It is important to educate plan members on their option to decline ISP reviews.
#1's father and step-mother did not receive the option to decline his ISP review documentation until 1/9/18. Individual #1 has had ISP reviews completed before 1/9/18.
ODP also stated that there was no documentation that the behavior specialist was offered the option to decline his ISP review documentation, however, on this form the behavioral specialist is marked as N/A because Individual 1 does not have a behavioral specialist.
QLS failed to explain that plan team members had a right to not receive the ISP quarterly review, however, the form does have a section that each plan team member can select if they ¿don¿t wish to.¿
By October 24, 2018, all family members will have been sent a memo explaining their right to not receive documentation of the ISP Quarterly Review.
A notice has been built into the database system that will generate at the bottom of each ISP Review notifying the team members of what steps they need to take to no longer receive the Quarterly ISP Reviews. Attachment #10 is a copy of a completed Quarterly Review that contains the notice for the team members. Each individual will have their information loaded into the database by November 1, 2018 and then the associated forms will be generated using this platform as they become due. As of November 1, 2018, all QLS managers will be trained on the use and production of this database which will be ensured by the operations department. |
10/24/2018
| Implemented |
| 6400.195(a) | Individual #1 and his housemate's board games, extra clothing, and other personal items that "didn't fit in their bedrooms" (per staff) was found locked and inaccessible in one of the upstairs bedrooms. There are no restrictive plans in place for either individual for having these items locked. (for 249 3rd Ave, Hastings, pa) | For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to use of restrictive procedures.
| It is important for the individuals to have access to their belongings, unless otherwise stated in a restrictive procedure plan.
Individual #1 and his housemate's board games, extra clothing, and other personal items that "didn't fit in their bedrooms" were locked and inaccessible in one of the upstairs bedrooms.
In attempt to keep the home clean and clutter free staff placed the belongings in a spare room but should not have locked it.
Upon the licensers exiting meeting on September 12, 2018 the home which was out of compliance with this regulation was contacted by their Program Specialist and informed that the items needed to be removed from the inaccessible area. Attachment #1 is an agency wide memo that was sent out on September 17, 2018, reminding staff that the individual¿s belongings must always be accessible to them without them asking to have access to them.
The Field Mangers checklist of regulatory items was revised to include inspection for any occurrences of the individual¿s items being inaccessible to them. This updated checklist is being forwarded to you as Attachment #2. The Field Manager is responsible for unannounced inspections of each residential location multiple times a month. The Field Managers Checklist will be reviewed weekly by the Operations Manager to see which areas we are lacking compliance in, so an internal corrective action can be implemented and/or revised. There was also a management meeting held on September 18, 2018 in which this citation was reviewed with the managers and they were instructed to be more vigilant while out at the homes to ensure compliance with this regulation. |
09/12/2018
| Implemented |
| 6400.212(b) | Staff #3 indicated to licensing on 9/11/18 that the physician left the TB spot on #1's 1/19/18 physical exam form blank and staff NW added "1/25/17" after she got back in the office. Staff #3 did not indicate their name or the date they added information to their' physical form. Individual #1 never received a TB skin test on 1/25/17. According to his immunization record, he received a tdap on 1/25/17.
-individual #1 had a dental form in his record from 3/14/18 that was a photocopy and everything on the form was photocopied except one item. There was an original pen mark "x" on the form next to the word "filling" but no indication of the staff who made the addition to the form or the date the "x" was added. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| It is important to know who accessed he individuals record and when it was completed.
QLS¿s prior Medical Coordinator, who was unlicensed, transcribed the wrong information on the individuals record and a form was altered without an indication of who altered it and when.
QLS believes it was an oversight on the previous Medical Coordinator.
This record was corrected with the licenser by the Operations Manager immediately upon her being made aware of the discrepancy.
On September 17, 2018 we filled our Medical Coordinator position with an LPN. This individual has an extensive background in home health and understands the importance of detailed documentation as well as the proper procedure when making notations on already completed documents. All documents completed by the Medical Coordinator are given to the Program Specialist for review and placement in the house books. Furthermore, on September 18, 2018 we reviewed with the management team the importance of documenting any changes or additions made to an individual¿s record by signing and dating the document. |
09/17/2018
| Implemented |
| 6400.213(11) | Individual #1's identification sheet in his record indicated he had no known drug allergies. They 1/19/18 and 1/18/17 physical examination forms indicated he had allergies to: Haldol, Vistaril, Lisinopril, Old bay seasoning, caffeine, citrus and chocolate. Individual #1's individual support plan (ISP) indicated he had no known allergies in the allergy section. According to printed emails in their record from his program specialist to his supports coordinator, there were multiple occasions where the program specialist indicated she reviewed the entire ISP and no changes needed to be made. This occurred on 7/12/18, 5/16/18, 3/13/18, 2/12/18, and 10/31/17. There were multiple other emails indicating other changes to the ISP that needed changed/updated but none of them expressed updating his allergies in his ISP. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | To be able to ensure the proper Health and Safety of the individuals that we support at QLS it is imperative that the individual¿s records are free from content discrepancy as stated in regulation 6400.213(11).
The physical contained discrepancies when compared to all other medical information for the individual in relating to his allergies.
As we looked into this issue it was evident that the physical was generated from another individuals physical instead of creating it from the master form.
On September 18, 2018, management held a meeting and discussed the importance of all content being the same. Through document review, Program Specialist completed notations within the individuals physical showing that they were made in error. The individual is currently scheduled for his annual physical in January 2019.
QLS is in the process of transferring our individual information to a database system that is going to automatically transfer most of their vital information to the associated forms so this data is only being managed in one centralized location and then fed to the appropriate documents so there is no more oversight of data or inaccurate data between documents which would include physicals, assessment, medical histories and ISP reviews. Each individual will have their information loaded into the database by November 1, 2018 and then the associated forms will be generated using this platform as they become due. Once the vital information is loaded and confirmed by the individual¿s team, the operations department would deny access to this vital information sheet acting as its supervisor for any additional changes or modifications. As of November 1, 2018, all QLS managers will be trained on the use and production of this database which will be ensured by the operations department. |
09/18/2018
| Implemented |