| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 died on the morning of May 23, 2019. The failure of the agency to protect Individual #1 from neglect resulting in his ultimate death was, the result of the lack of management oversight and training of staff. The toxicology report indicated there was only Vimpat in his blood. He was to have had Metformin ER at 5pm and Levetiracetam at 8pm, and neither were found in his blood. Staff #1 stated in interviews that he checked individual #1 every hour from the doorway, and was not trained that the Individual Support Plan (ISP) required checks every 30 minutes, and was not trained on how to evaluate the 3 health items on the "CL PA Overnight Supervision Report" for breathing, incontinence, and signs of illness. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | As part of Delta's internal investigation, the certified investigator spoke with the coroner on 8/27/19. The coroner informed our investigator that the only medication tested as part of the toxicology screening was the Vimpat. Metformin ER and Levetiracetam were not part of the testing. The internal investigation also determined that the target of the investigation, Staff #1, was trained in individual #1's ISP on 10/28/18 (Attachment # 4) At the conclusion of the investigation, the employment relation with Staff #1 was ended on 9/17/19. As part of the corrective action for the investigation, a Sleep Check training was developed by the agency nurse on 9/11/19 and all staff were trained 9/14/19-11/20/19. (Attachments #5 &6) There is currently an investigation being completed by the Warminster Township Police Department. They have secured an expert to analyze the findings of the toxicology report. Delta has secured legal counsel regarding the findings of the investigation and coroner's report. |
11/20/2019
| Not Implemented |
| 6400.43(b)(1) | Staff #1 was not trained properly on how to use the "CL PA Overnight Supervision Report". The report states all bed checks are to be checked to determine the health status of each consumer. They are to be checking for breathing, incontinence, and signs of illness. The witness stated the staff that they do hourly checks from the bedroom door and there was no clear expectation of how staff were to check the three health items identified by management on these overnight supervision reports.
Specific contributing factors that contributed to individual #1's death were, 30-minute checks were not completed, medication were not administered, staff role in "checks" are unclear with no clear expectations or training as well as significant lack management presence and administrative oversight within the organization. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Delta completed an internal investigation and the certified investigator arrived at the home on the morning of the incident and checked medications. The certified investigator states that there were no medications in the blister packs leading the investigator to determine that all medications were administered as prescribed. While the medications were administered as prescribed, the investigation did determine that two of the medications were not signed for, Metformin and Levetiracetam indicating a documentation error.
Both staff identified in the investigation are no longer employed by Delta so no follow up training was able to occur with them. Going forward, the remaining staff in the home will be retrained in medication administration and documentation procedures to assure their understanding of medication administration and documentation.
As part of the corrective action for the investigation, a Sleep Check training was developed by the agency nurse on 9/11/19 and all staff were trained 9/14/19-11/20/19. (Attachments #5 & 6) Delta has secured legal counsel regarding the findings of the investigation and coroner's report. |
01/15/2020
| Not Implemented |
| 6400.64(a) | The Main bathroom had mildew present. | Clean and sanitary conditions shall be maintained in the home. | Bathroom shower has been re-caulked on 9/17/19 and mildew is removed. (Attachment # 7)
A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. |
02/01/2020
| Implemented |
| 6400.67(a) | The main bathroom wooden floor vent was unattached and dirty.
The Basement handrail was loose. | Floors, walls, ceilings and other surfaces shall be in good repair. | The bathroom vent was cleaned and secured on 9/17/19. (Attachment # 8 ) The handrail to the basement has been secured on 9/13/19. (Attachment # 9)
A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. |
02/01/2020
| Implemented |
| 6400.67(b) | Individual #3's bedroom wall had a broken electrical receptacle.
The basement dryer foil vent was full of lint, and had loose lint surrounding the dryer. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Outlet cover in individual #3's bedroom has been fixed on 9/13/19. (Attachment # 10) The basement dryer flex hose has been cleaned out on 9/26/19 (Attachment # 11) A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. |
02/01/2020
| Implemented |
| 6400.76(a) | In Individual #2's bedroom, the chest of drawers was not on the track.
In individual #3's bedroom, the chest of drawers has 2 drawers not on the track. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The facilities department replaced missing screws on Individual # 2's and #3's dresser drawers to fix the guides on the drawers on 9/17/19. (Attachment #12 ) A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. |
02/01/2020
| Implemented |
| 6400.80(a) | The outside ramp on the flooring it was peeling, and needs to be painted. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The outside ramp has been repainted on 9/19/19. (Attachment #13) A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. |
02/01/2020
| Implemented |
| 6400.165(c) | Individual #1's Individual Support Plan (ISP) listed Medications for seizures as Levetiracetam (Keppra) 1000mg given 2 times a day at 8am and 8pm, medication Vimpat 100mg given 2 times a day at 8am and 8pm. Individual #1 also takes diabetes medication Metformin ER (Glucophage XR) 2 tablets of 500mg 1 times a day at 5pm. However, the coroner's toxicology reports the only medication that was found was Vimpat 1.2mcg/ml , which the normal range would be 4.99mcg/ml+/- 2.51mcg/ml, and no other medications were found. | A prescription medication shall be administered as prescribed. | As part of Delta's internal investigation, the certified investigator spoke with the coroner on 8/27/19. The coroner informed our investigator that the only medication tested as part of the toxicology screening was the Vimpat. Metformin ER and Levetiracetam were not part of the testing. The internal investigation also determined that the target of the investigation, Staff #1, was trained in individual #1's ISP on 10/28/18 (Attachment #4) There is currently an investigation being completed by the Warminster Township Police Department. They have secured an expert to analyze the findings of the toxicology report. Delta has secured legal counsel regarding the findings of the investigation and coroner's report. |
12/13/2019
| Not Implemented |
| 6400.186 | Individual #1's Individual Support Plan (ISP) for the plan year of 7/1/18-6/30/19, in the supervision care needs section states, "Individual #1 requires within the building supervision, when in the home he can be left alone in his room with routine checks every 30 minutes. The staff were documenting these checks on the "CL PA Overnight Supervision Report" every hour, which is not implementing what is in the ISP. | The home shall implement the individual plan, including revisions. | Delta completed an internal investigation and the investigation determined that the target of the investigation, Staff #1 was trained in individual #1's ISP on 10/18/18 (Attachment #4) At the conclusion of the investigation, the employment relation with Staff #1 was ended on 9/17/19.
As part of the corrective action for the investigation, a Sleep Check training was developed by the agency nurse on 9/11/19 and all staff were trained 9/14/19-11/20/19. (Attachments #4 & 5) |
11/20/2019
| Not Implemented |