| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #1 is not safe around poisonous materials. The unlocked soap (Assure Foam Clean) in the dispensers of both bathrooms, states to notify poison control if ingested. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Who: All staff in the ID Residential Program
What: Ensure that all individual's annual assessments and ISP is implemented as written regarding the individual's safety around poisonous materials, by either keeping them locked or inaccessible to the individual
When: At all times
How:
1. Annual assessment was modified to break down the category of poisonous materials to include subcategories: personal hygiene, cleaning supplies and other (i.e. gasoline, motor oil, etc.)
1A Assessment was updated for all individuals in the 14 group homes.
2. Removal of soap dispenser at two of the 14 homes where individual who were assessed as not safe with any poisonous materials.
2A non-toxic soap was purchased for these homes.
3. Retraining for all staff
Attachments:
C.1 Individual #1's updated assessment and email showing changes were sent to the SC (3 pages)
C.2 email to the supervisor of the 2 homes where the individuals are assessed as not being safe with any poisonous materials.
C.3 2 receipts from Amazon showing that non-toxic soap was purchased - including MSDS
C.4 emails and pictures showing that the hand dispensers were removed from 2 of the 14 homes.
C 5 retraining for all staff - see signature sheet for staff |
11/24/2021
| Implemented |
| 6400.212(b) | Entries documented on Individual #1's bowel movement protocol are consistently illegible. It is difficult to decipher if Individual #1 had no bowel movement or had diarrhea. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| Who: All staff
What: ensure that all entries are legible as per chapter 6400.212(b)
When: at all times
How:
1. Bowel Chart was modified to remove zero with a strike through and a D, which is what caused the non-compliance, as staff wrote a zero and did not put a strike through line.
2. Retraining all staff were retrained on the importance of legible entries
Attachments.
D.1 updated BM chart that has been implemented
D.2 signature sheet showing staff was retrained in regulations |
11/24/2021
| Implemented |
| 6400.165(g) | The quarterly medication review that occurred on 11/2/20 and 10/20/21 for Individual #1 was completed by an RN; not a licensed physician as regulations require. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Who: All staff within the ID Residential Department who accompanies an individual to a psychiatric appointment or reviews medical paperwork.
What: ensure that the prescribing physician signs the paperwork on a quarterly basis
When: Whenever any individual is seen by a psychiatrist or a medical professional that prescribes medication to treat symptoms of a psychiatric illness (Please note that some of the individual's PCP prescribe medication for a psychiatric illness.)
How:
1. The Quarterly Review of the Psychiatric Medication form was updated to include the statement:
*THIS FORM CAN ONLY BE SIGNED BY THE PRESCRIBING PHYSICIAN AS PER 55 PENNSYLVANIA CODE CHAPTER 6400.165 (G)
2. All staff were retrained on 55 PA Code Chapter 6400.165(g).
a. All staff are aware that when they accompany an individual to a psychiatric appointment for the individual's quarterly medication review or more frequent appointments if warranted, that the staff must verify that it was the prescribing physician (medical personnel) that signed the paperwork.
i. Licensed medical professionals that can prescribe medications include:
1. Doctor of Medicine (MD)
2. Doctor of Osteopathic Medicine (DO)
3. Physician Assistants (PA)
4. Nurse Practitioner or Certified Registered Nurse Practitioner (NP or CRNP)
ii. A Registered Nurse (RN) or a Licensing Practical Nurse (LPN) cannot prescribe medication OR sign the Quarterly Review of the Psychiatric Medication form
3. Notifying all medical facilities that provide services to the individuals we serve of PA Code Chapter 6400.165(g), which is state law.
Attachments:
E.1 implemented copy of the updated Quarterly Review of the Psychiatric Medication form was updated to include to include the statement: *THIS FORM CAN ONLY BE SIGNED BY THE PRESCRIBING PHYSICIAN AS PER 55 PENNSYLVANIA CODE CHAPTER 6400.165 (G)
E.2 signed signature sheet showing that staff were retrained and received a copy of the updated form
E.3 Letter that was sent to medical facilities and fax cover sheets and verification that the faxes were sent. |
11/24/2021
| Implemented |