| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | At the time of the 8/22/23 inspection, the temperature of the hot water in the hallway bathroom sink was measured at 123.6°F. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | The temperature setting on the water heater was turned down at the time of the licensing inspection to a setting that resulted in the temperature being below 120 degrees Fahrenheit. Attachment 1a
The Property Management Company serviced the water heater and replaced the temperature gauge. |
08/27/2023
| Implemented |
| 6400.110(a) | At the time of the 8/22/23 inspection, the smoke detector in the basement was not fully operable. It made noise when tested, but it was warped as if the battery needed replaced and it was not loud enough to be heard on other floors. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | The battery in the smoke detector was replaced. |
08/23/2023
| Implemented |
| 6400.144 | (Repeated Violation -- 2/1/23) Individual #1 has a bowel management protocol in place that indicates that Individual #1 should be given Benefiber supplement daily and 2 tablets of Senna as needed in the pm for constipation. Individual #1's Medication Administration Records also indicate that Senna's instructions are "Take 2 tabs in PM as needed." Individual #1's Individual Support Plan states, "Daily and PRN medication if no bowel movement in 3 days." There are no further instructions on what staff should do if the Senna medication is not effective. Additionally, Individual #1's Benefiber was discontinued on 6/13/23, so this bowel management protocol is out of date.
Individual #1 was administered Senna PRN on the following dates and times, but it was administered inconsistently, and it is unclear as to how the determination was made that the medication was needed:
· 6/22/23 8pm -- this was the 5th recorded day with no bowel movement
· 7/11/23 8:30pm -- this was the 4th recorded day with no bowel movement
· 7/25/23 8:30pm -- this was the 2nd recorded day with no bowel movement
· 8/8/23 8:30pm -- this was the 2nd recorded day with no bowel movement
· 8/10/23 7:15am and 8:00pm -- Individual #1 had a bowel movement on 8/9/23.
· 8/11/23 7:15pm -- this was the 2nd recorded day with no bowel movement
Additionally, Individual #1 did not have a documented bowel movement on 6/5/23, 6/6/23, and 6/7/23, but no PRN medication was administered.
Individual #1 has a history of falls, including unwitnessed falls. The Fall Protection/Prevention plan currently in place does not detail what staff should do in the case of a fall, whether witnessed or unwitnessed. Individual #1 had unwitnessed falls on 6/14/23, and 8/10/23. Individual #1's daily notes on 6/5/23 indicated that Individual #1 had 2 bruises on their knee and an inch and a half long bruise on their side, and no follow up action was taken to determine if a fall occurred, how the injury occurred, or if there were any further medical follow-ups completed.
Individual #1's physician ordered bloodwork on 6/27/23 and listed the requested timeframe as "immediate." At the time of the 8/22/23 inspection, there is no record that this bloodwork was completed. | 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.
| Individual#1's bowel management protocol has been updated to reflect current physician instructions. Staff have been retrained in the documentation of bowel activity and the necessity of recent bowel activity being reviewed to determine if medication is needed. Attachment 2
Individual #1's Fall Protection/Prevention plan has been updated to include instructions regarding what staff should do in the case of a fall, witnessed and unwitnessed. All staff have been trained in the revised plan and the proper documentation of falls within the electronic record keeping system. Attachment 3
Physician's order for bloodwork was completed on 8/29/23 Attachment 4 |
09/11/2023
| Implemented |
| 6400.214(b) | Individual #1's most recent Individual Support Plan (ISP) update was completed on 8/7/23. The most recent ISP available in the home was dated 6/21/23. There was no assessment present for Individual #1 at the home.
Individual #2's most recent ISP update was completed on 8/7/23. The most recent ISP available in the home was dated 6/12/23. There was no assessment present for Individual #2 at the home. | The most current copies of record information required in § 6400.213(2)(14) shall be kept at the residential home. | The most recent ISP update was done to document the change of Support Coordinator for Individual #1 and #2. The Provider was not notified of the change until 8/29/23. Attachment 6a Attachment 6b
Copies of these documents have been placed in the home along with a copy of the most recent assessment. |
09/11/2023
| Implemented |
| 6400.52(c)(1) | Staff person #1's annual training hours for July 1, 2022 -- June 30, 2023, did not include the trainings required in person-centered practices, community integration, individual choice, or supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff person #1 has completed all required trainings for the current training year. Attachment 7 |
09/11/2023
| Implemented |
| 6400.52(c)(2) | Staff person #1's annual training hours for July 1, 2022 -- June 30, 2023, did not include the trainings required in the prevention, detection, and reporting of abuse. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Staff person #1 has completed all required trainings for the current training year. Attachment 7 |
09/11/2023
| Implemented |
| 6400.52(c)(3) | Staff person #1's annual training hours for July 1, 2022 -- June 30, 2023, did not include the trainings required in individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff person #1 has completed all required trainings for the current training year. Attachment 7 |
09/11/2023
| Implemented |
| 6400.52(c)(4) | Staff person #1's annual training hours for July 1, 2022 -- June 30, 2023, did not include the trainings required in recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Staff person #1 has completed all required trainings for the current training year. Attachment 7 |
09/11/2023
| Implemented |
| 6400.52(c)(5) | Staff person #1's annual training hours for July 1, 2022 -- June 30, 2023, did not include the trainings required in the use of safe and appropriate behavior supports. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Staff person #1 has completed all required trainings for the current training year. Attachment 7 |
09/11/2023
| Implemented |
| 6400.163(d) | Individual #1 has daily and PRN prescriptions for Clonazepam, a controlled substance. At the time of the 8/22/23 inspection, this medication was not double-locked per regulations. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | A locked container has been purchased to secure controlled substances and is kept within the locked area designated for medications. Attachment 8 |
09/11/2023
| Implemented |
| 6400.165(a) | (Repeated Violation -- 2/1/23) At the time of the 8/22/23 inspection, Individual #1 had the following OTC medications present in their medication box that do not have a written order, including standing orders, from the physician: Benadryl Liquid Gels, Chest Rub, DG Nighttime Cold and Flu, and QC Nondrowsy Daytime Multi-Symptom Cold and Flu. | A prescription medication shall be prescribed in writing by an authorized prescriber. | All OTC medications that do not have a specific written order have been removed from the home. |
09/11/2023
| Implemented |
| 6400.165(b) | (Repeated Violation -- 2/1/23) Individual #1's physician discontinued Benefiber on 6/13/23. This discontinuation was not put into place in the home until 6/20/23.
Individual #1 has 2 different PRN medications listed for both "Anti-diarrheal" and "Constipation" on their August 2023 Medication Administration Record. Both instructions indicate to "follow labeled instructions for dose and administration of OTC medications." Tylenol Cold and Flu is also listed with the same directions. These orders were not updated by the physician to include accurate dosing information and clarify which medication should be used. | A prescription order shall be kept current. | The Benefiber was discontinued on 6/20/2023.
The Medication Administration Record has been updated to reflect one PRN medication for Constipation and one OTC medication for diarrhea including accurate dosing. Attachment 9 |
09/11/2023
| Implemented |
| 6400.165(c) | (Repeated Violation -- 2/1/23) On 6/13/23, Individual #1's physician ordered a one-time dose of Magnesium Citrate to be administered to complete a "clean out." This medication was administered on 6/16/23 at 6:30pm. After the magnesium citrate was administered, Individual #1 was to start Miralax, one capful in 8 ounces of non-carbonated liquid daily. The first administration of this medication did not occur until 6/21/23. | A prescription medication shall be administered as prescribed. | It was unclear as to how soon after the Magnesium Citrate was complete, the Miralax was to begin. Clarification should have been sought at that time as to whether it was to begin after the effects of the Magnesium Citrate had subsided or if was to begin the next day or after the weekend. This led to the delay in beginning the Miralax. The letter from the Gastrologist to the PCP states that the Benefiber is probably ineffective and could be discontinued. It was unclear within the context of a letter between physicians, if "probably" and "could" constitute a physician's order. All staff have been instructed to seek clarification from the administrative staff in the event of any uncertainty that pertains to medical treatment. The Health Coordinator shall contact the physician for clarification as needed. Attachment 10 |
09/11/2023
| Implemented |
| 6400.166(a)(9) | Individual #1's PRN Senna medication label at the home indicates that Individual #1 is to, "Take 2 tabs by mouth in the evening if no bowel movement in 3 days." The Medication Administration Record states, "Take 2 tabs in PM as needed." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The instructions on the MAR have been updated to say Take 2 tabs in PM if no BM in 3 days Attachment 9 |
09/15/2023
| Implemented |
| 6400.166(a)(15) | Individual #1's Ferrous Sulfate medication label at the home indicates that the medication is to be taken "with or immediately after food." This special precaution is not noted on Individual #1's Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | The Instructions on the MAR have been updated to include Take with or immediately after food. Attachment 9 |
09/15/2023
| Implemented |
| 6400.166(b) | The following medications were administered to Individual #1 and were not documented at the time of administration:
· 6/1/23 -- all 8pm medications
· 6/2/23 -- all 6am and 8pm medications
· 6/4/23 -- all 7am medications
· 6/5/23 -- all 5pm medications
· 6/8/23 -- all 5pm medications
· 6/13/23 -- all 5pm medications
· 6/20/23 -- all 5pm medications
· 6/27/23 -- all 8pm medications
· 7/4/23 -- all 5pm medications
· 7/10/23 -- all 5pm medications
· 7/17/23 -- all 5pm medications
· 7/22/23 -- all 8pm medications
· 7/29/23 -- all 5pm and 8pm medications | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Written communication has been sent to all staff stressing the requirement that all medications be given and documented within 1 hour before or after the prescribed time. Attachment11
The Health Coordinator is reviewing the Therap report daily to identify staff who have violated this requirement and reinstructing them on the proper procedure. Staff who are repeat offenders after being contacted have received written disciplinary action. Attachment 12 |
09/11/2023
| Implemented |
| 6400.167(a)(1) | (Repeated Violation -- 2/1/23) Individual #1 did not receive their 7am dose of Divalproex Sodium on 8/17/23. | Medication errors include the following: Failure to administer a medication. | Staff on duty at that time verified that the medication was administered and witnessed by supervisor however it was not documented. Once contacted, the responsible staff documented the administration as being given and added a comment to explain the documentation error. This correction did not occur until 8/22/23. Written communication has been sent to all staff stressing the requirement that all medications be given and documented within 1 hour before or after the prescribed time. Attachment11
The Health Coordinator is reviewing the Therap report daily to identify staff who have violated this requirement and reinstructing them on the proper procedure. Staff who are repeat offenders after being contacted have received written disciplinary action. Attachment 12 |
09/11/2023
| Implemented |
| 6400.167(a)(3) | Individual #1's June, July, and August 2023 Medication Administration Records indicate that the Individual should be taking 3.4ml of Ferrous Sulfate on Monday, Wednesday, and Friday. The actual medication labels present on the medications at the home indicate that the individual is to be taking 2ml on Monday, Wednesday, and Friday. Individual #1's 6/27/23 physical after-visit summary, which is from the prescribing doctor for the Ferrous Sulfate, indicates that the dosage should be 2ml, not 3.4ml. Individual #1 has been administered the wrong dose since at least 6/1/23. | Medication errors include the following: Administration of the wrong dose of medication. | As indicated by the inspection citation, the dosage on the medication label indicates 2ml on Monday Wednesday and Friday. The MAR has been corrected to reflect the proper dosage instructions. Attachment 9 |
09/11/2023
| Implemented |
| 6400.167(a)(4) | The following medications were administered to Individual #1 more than 1 hour before or after the prescribed time:
· 6/1/23 -- all 8am medications
· 6/2/23 -- all 6am medications
· 6/3/23 -- all 6am and 5pm medications
· 6/4/23 -- all 5pm medications
· 6/5/23 -- all 6am medications
· 6/6/23 -- all 5pm medications
· 6/7/23 -- all 6am medications
· 6/8/23 -- all 8am medications
· 6/9/23 -- all 6am medications
· 6/10/23 -- all 8am medications
· 6/11/23 -- all 6am and 7am medications
· 6/13/23 -- all 8am medications
· 6/14/23 -- all 6am medications
· 6/15/23 -- all 6am and 7am medications
· 6/16/23 -- all 6am and 7am medications
· 6/17/23 -- all 7am medications
· 6/19/23 -- all 7am medications
· 6/20/23 -- all 8am medications
· 6/22/23 -- all 8am medications
· 6/23/23 -- all 6am and 7am medications
· 6/24/23 -- all 6am and 7am medications
· 6/25/23 -- all 8am medications
· 6/26/23 -- all 6am medications
· 6/27/23 -- all 6am medications
· 6/29/23 -- all 6am medications
· 6/30/23 -- all 6am medications
· 7/1/23 -- all 6am, 7am, and 8am medications
· 7/2/23 -- all 7am medications
· 7/3/23 -- all 6am medications
· 7/5/23 -- all 6am, 7am, and 8am medications
· 7/7/23 -- all 5pm medications
· 7/10/23 -- all 8am medications
· 7/12/23 -- all 6am medications
· 7/13/23 -- all 8am medications
· 7/14/23 -- all 6am and 7am medications
· 7/15/23 -- all 6am medications
· 7/16/23 -- all 7am medications
· 7/17/23 -- all 6am medications
· 7/19/23 -- all 6am medications
· 7/21/23 -- all 6am medications
· 7/22/23 -- all 6am, 7am, and 8am medications
· 7/23/23 -- all 7am medications
· 7/24/23 -- all 6am medications
· 7/25/23 -- all 6am and 5pm medications
· 7/26/23 -- all 6am medications
· 7/27/23 -- all 6am and 5pm medications
· 7/28/23 -- all 6am, 7am, and 8am medications
· 7/30/23 -- all 7am medications
· 7/31/23 -- all 6am medications
· 8/1/23 -- all 5pm medications
· 8/2/23 -- all 6am medications
· 8/4/23 -- all 6am and 5pm medications
· 8/5/23 -- all 6am, 7am, and 8am medications
· 8/6/23 -- all 8am medications
· 8/7/23 -- all 8am medications
· 8/8/23 -- all 8am medications
· 8/10/23 -- all 6am and 5pm medications
· 8/12/23 -- all 6am and 7am medications
· 8/13/23 -- all 7am and 5pm medications
· 8/14/23 -- all 6am medications
· 8/15/23 -- all 8am medications
· 8/16/23 -- all 6am medications
· 8/17/23 -- all 6am and 8am medications
· 8/18/23 -- all 6am medications
· 8/19/23 -- all 6am, 7am, and 5pm medications
· 8/21/23 -- all 8am medications
· 8/22/23 -- all 8am medications | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | Written communication has been sent to all staff stressing the requirement that all medications be given and documented within 1 hour before or after the prescribed time. Attachment 11 The Health Coordinator is reviewing the Therap report daily to identify staff who have violated this requirement and reinstructing them on the proper procedure. Staff who are repeat offenders after being contacted have received written disciplinary action. Attachment 12 |
09/11/2023
| Implemented |
| 6400.167(b) | There is no documentation of the medication errors or the prescriber's instructions for the errors described in 6400.167a1, 6400.167a3 and 6400.167a4. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | The medication errors identified have been entered into EIM.
The Program Specialist has been trained in entering medication errors into the General Event Record section of the individual record. Attachment 14 |
09/11/2023
| Implemented |
| 6400.167(c) | The medication errors described in 6400.167a1, 6400.167a3 and 6400.167a4 were not reported as incidents in the department's incident management system. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | Medication errors have been entered into EIM for all of the above where there was no documentation that the medication was administered one hour before or after the prescribed time. |
09/11/2023
| Implemented |
| 6400.169(a) | Staff person #1 has not received training in administered medication via routes other than oral. Staff person #1 has administered topical medication and nasal spray to Individual #1. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Staff #1 has obtained training from a Registered Nurse instructing staff on the proper administration of topical medications. Attachment 15 Staff #1 will receive training on administering medications via nasal spray. |
09/15/2023
| Implemented |