| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.33(d) | Individual #1's psychiatrist indicated on the individual's psychiatric medication review "reviewed behavioral issues. Patient is well aware of behavior problems, attention seeking behavior. patient needs a behavior therapist to improve at this time." Staff #1 did not initiate a referral for behavior support until 9/1/18. Staff #1 indicated to licensing on 10/4/18 that the referral did not happen until 9/1/18 because The ARC of Centre County 6400 agency wanted to use their own behavior support person. Individual #1 was never asked what behavior support provider the individual would like to utilize. | An individual has the right to participate in program planning that affects the individual. | The team was asked when the referral was made by the psychiatrist, who the family and Indiviudal #1 wanted. They wanted the current person that was in the home for another individual, who we were contracting at the time with through another agency. This person, Maddie Sell, was offered a positon with us in late June but was not able to start until August 1. The family and team were ok with him starting in mid-October for Maddie to complete inner agency training. A training is also attached to show if this occurs again that a team meeting will be held and a signature sheet with an outcome paragraph will be submitted and the responsible people are the LPN supervisor and DON/program Specialist. Services did start on 10/15/2018. |
10/15/2018
| Implemented |
| 6400.141(c)(9) | Individual #1's 1/31/18 physical exam did not include a prostate exam. Individual currently takes Tamsulosin daily for Benign Prostatic Hyperplasia (BPH). | The physical examination shall include: A prostate examination for men 40 years of age or older. | Several calls to Dr. Hollencik, general practitioner, was placed. She is not happy about being questioned but is to send a letter explaining the medical guideline requirements. It should be noted: His Tamulsin is for incontinence not BPH. Both the DON and LPN Supervisor were both responsible that if the letter is not here by 11/15/2018, they must obtain a second opinion for the prostate. |
11/15/2018
| Implemented |
| 6400.144 | Continued from above. Individual #1's doctor signed verbal order on 4/23/18 to d/c order for left posterior thigh cleanse wound with normal saline aquasil to wound cover with ABD pads and hypofix tape daily as needed. Start new order for cleanse wound to left posterior thigh with normal saline apply aquacel silver to wounds then cover with sterile dressing and change every three days or as needed for soiling. The new order was actually order on 4/17/18 by doctor was Geisinger. According to the treatment record it indicated the left posterior thigh wound, clean with soap and water, pat dry, apply xerofoam to open areas then apply with antifungal cream to periwound, cover with ABD pad, apply skin prep to perimeter of entire wound, apply omnifix tape to secure dressing, change once daily or as needed for soiling was started on 4/28/18. The doctor's order doesn't match the treatment record that was completed for Individual #1, nor was it started in timely manner.
-Individual #1 has an order to use spirometer 3 times daily , 5-10 per incident 9/10/18. The treatment record indicated spirometer 3 times daily 5 inhales each time. The order doesn't match the log. The treatment record was not initialed at 8am on 10/4/18 and 10/5/18 as being completed.
-Individual #1 has an order to discontinue sensicare on 10/2/18. Sensicare was initialed as administer on 10/2/18 for the 7am-3pm shift and 11pm-7am(into the 3rd) shift. The log needs to indicate the time of shift and staff shouldn't be initialing for the next day.
--Individual #1 has an order to use "nocturnal pulse ox should be completed to determine oxygen needs as needed." Also has an order to "administer oxygen via N.C. at 2L per minute prn S.O.B." There is no order to define at what oxygen saturation level Individual #1's pulse oxygen machine should read in order to start administering oxygen. There is also no order to determine at what level of oxygen saturation Individual #1's levels need to return to in order to stop administering the oxygen.
--9/10/18 Individual #1's physician wrote an order for spirometer 3xday 5-10time per incident. Spirometer was not used until 8am on 9/19/18. It then wasn't used the other two times on 9/19/18. | 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.
| The order date was 4/17/18, but we did not receive it until 4/18/18 per fax time stamp received. As per the MAR it was started on 4/18/2018 not 4/23/18. When it was received on 4/18/18 it was started that day and as our agency policy we have 24 hours to obtain a new medication, it was met on 4/18/2018.
A clarification order was obtained on 9/18/18 to show the exact amount of inhales, due to needing to be sure the exact inhales were being administering. It matches the MAR and was implemented as such.
Training on 10/28/2018, was completed to ensure that from this point on that any medication administered during the overnight shift that an exact time of administration be placed on MAR to show it was administered prior to discontinuation.
An order for more clarification on needs during the overnight was obtained. Oxygen is only for night time use, pulse-ox is discontinued on 10/15/18.
It was founded that LPN¿s did not sign off on the Mar. A re-training was completed and agency discipline was administered to prevent further documentation errors. |
10/15/2018
| Implemented |
| 6400.144 | Individual #1's psychiatrist indicated on the individual's psychiatric medication review 7/2018 "reviewed behavioral issues. Patient is well aware of behavior problems, attention seeking behavior. patient needs a behavior therapist to improve at this time." The program specialist, Staff #1, did not initiate a referral for behavior support until 9/1/18. Staff #1indicated to licensing on 10/4/18 that the referral did not happen until 9/1/18 because The ARC of Centre County 6400 agency wanted to use their own behavior support person. Individual #1 was never asked what behavior support provider the individual would like to utilize. According to daily documentation Individual #1 was indicating that individual "just wanted to give up" on 8/8/18. Also had behaviors recorded. ISP states Individual #1 has been making statements of wanting to harm self and housemates at times.
--Individual #1 is diagnosed with asthma, congestive heart failure and chronic respiratory failure and is prescribed Proair Hfa 90 mcg inhale two puffs by mouth every 4 hours as needed for shortness of breath or wheezing. The residential facility does not make this available when attending day program daily.
-- Individual #1 is prescribed Albuterol Sulf. Neb. Use 1 vial in nebulizer every 4 hours as needed for cough/wheezing. The residential facility does not make this available when attending day program daily.
-- Individual #1 is prescribed Oxygen via N.C. at 2L per minute as needed S.O.B. The residential facility does not make this available when attending day program daily.
--Individual #1's medication administration record indicated that a nocturnal pulse oxygen should be completed to determine oxygen needs as needed. The residential facility did not relay this information to the day program facility, or ensure that a pulse oxygen machine is available at day program.
--Individual #1's September 2018 treatment record indicated that the individual was to have "left posterior thigh wound, cleanse wound with soap and water. Pat dry. Apply xeroform to open areas. Then apply antifungal cream to peri wound. Cover with ABD pad. Apply skin prep to the perimeter of the entire wound. Apply omnifix tape to secure dressing. Change once daily or as needed for soiling." These medications, medical equipment and medical instructions were never passed on to the individual's day program by the individual's residential program.
--Individual #1's April to September 2018 treatment record indicated that the individual was to have sensicare applied "to buttocks and left thigh every shift and with incontinence to prevent skin breakdown." 4/3/18 order for sensicare indicated to apply to buttocks after every brief change. The residential facility did not relay this information to individual's day program facility, or ensure that a sensicare is available at day program.
-verbal order given by Individual #1's doctor on 4/26/18 to apply SCDS to lower legs BID for 20 mins daily while in bed. According to treatment record, this was not initiated until 4/29/18.
Continued. | 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.
| The team was asked when the referral was made by the psychiatrist, who the family and Individual #1 wanted. They wanted the current person that was in the home for another individual, who we were contracting at the time with through another agency. This person, Maddie Sell, was offered a positon with us in late June but was not able to start until August 1. The family and team were ok with him starting in mid-October for Maddie to complete inner agency training. A training is also attached to show if this occurs again that a team meeting will be held and a signature sheet with an outcome paragraph will be submitted and the responsible people are the LPN supervisor and DON/program Specialist. Services did start on 10/15/2018.
Attached is a guideline/communication sheet signed by the Arc DON and Heather Cassidy from Sunny Days day Programming what the expectations are for Shawn if he is in respiratory distress, needed treatment and or medications on 10/25/2018. A more concise Dr. order was updated to indicate oxygen is only for night time use, pulse-ox is discontinued and the proair was discontinued due to non-use. Sensi-care was discontinued on October 2, 2018.
Individual #1 refused to wear the SIDS and an order was obtained to discontinue them. Attached is the D/C order. |
10/15/2018
| Implemented |
| 6400.185(b) | Individual #2's ISP said the individual should be repositioned frequently but typically refuses to allow staff to do so. the individual should be transferred into bed to get off of buttocks during the day but refuses to do so. No documentation of transferring the individual to bed when at home or repositioning frequently. | The ISP shall be implemented as written. | On 10/24/2018, staff were retrained on a new overnight tracking form with all the nurses to be more description on two hour checks. A training form is attached to show completion of this and it¿s implementation. The request was made on 10/31/2018 to update the ISP to indicate that he refuses to be repositioned although he has been educated of the risk. The LPN supervisor and Director of Nursing/Program Specialist will ensure this documentation is completed. |
10/24/2018
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include a current dated photograph. There wasn't a photograph in the record at all. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.
| A re-training was completed and a review that the LPN supervisor will ensure that a new picture will be added yearly at the same time as regulation paperwork is due. A picture was added to the general binder and is in the attached documents. |
10/22/2018
| Implemented |