| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | The hand soap in the kitchen and the basket of soaps, lotions and sprays in individual #1's bedroom contain poisonous materials. Their ISP suggests poisons should be locked away -- their assessment was requested for further clarification, but this was not provided. | Poisonous materials shall be kept locked or made inaccessible to individuals. | It is essential that all poison materials be kept locked and separate from food items. The team determined that the resident can safely handle and has the right to easily access toiletry supplies such as toothpaste, soap, body wash, deodorant, perfume. The program specialist documented this addendum to the ISP and sent to the Supports Coordinator to update the ISP accordingly (Attachment #3). |
11/19/1924
| Implemented |
| 6400.144 | The following PRN medications for individual #1 were not found during inspection: Acetaminophen 325mg tablets, Banophen 25mg capsules, Orabase 20% Benzocaine. Staff member #2 did not receive training on the Individual Care Plan for Individual #1's foley catheter and was the only staff member on shift during inspection. -- inadequate medical care for this device can lead to bodily harm without appropriate training. | 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 essential the direct care staff receive individual specific training on care plans and ISP's to effectively support the needs of the individual. Staff#2 received this training on 11/19/24 (Attachments #5 and #6).
All medication as prescribed must be present in the home and available to the resident. These PRN medications were re-ordered and have been received (Attachments #8 and #9). |
11/19/2024
| Implemented |
| 6400.32(r) | The bedrooms did not have locks on the doors, and no refusal of locks was noted in Individual #1s' ISP. | An individual has the right to lock the individual's bedroom door. | CADES failed to ensure the individual right to privacy by ensuring locks were on the bedroom door. A work order was placed, and locks were added to the bedroom doors (Attachment #1). |
10/25/2024
| Implemented |
| 6400.45(d) | Individual #1's ISP indicates the needs for 2:1 staffing. During the inspection, only one staff member was scheduled for their address. | The staff qualifications and staff ratio as specified in the individual plan shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c ). | The level of supervision in Individual #1's ISP at the time of the inspection was based upon a period of time during which Individual #1 had increased behavioral health needs which have subsequently resolved. They had supplemental habilitation service authorizations for increased level of supervision from 7/1/23 to 9/9/23 and 10/6/23 to 12/29/23. After Individual #1's behavioral health needs had resolved and the increased level of supervision was no longer required, the Program Specialist did not adequately follow through with Individual #1's Support Coordinator to ensure a critical revision of the ISP was completed. In response to this citation, the Program Specialist reached out to the Supports Coordinator to remove old language from the ISP that reflects higher supervision levels from that time. Individual #1 does not require a 2:1 ratio of support and can be safely supervised with one staff present in her home. The correspondence reflecting this change in supervision will be included in the individual's program book, Electronic Health Record, and all training materials for staff. Target date 11/19/24. |
11/19/2024
| Not Implemented |
| 6400.50(a) | Staff #1 and #2 are not listed on the ISP training for individual #1's or individual #1's catheter training. Those are the 2 staff observed working with individual #1 during the visit. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Staff 1 and 2 were trained in the individual's catheter care plan and signed off on this training. It is essential that all staff be trained in this care plan specific to the individual's needs to ensure the individual's health and safety. Target date 11/21/24. |
11/21/2024
| Not Implemented |
| 6400.52(c)(6) | Staff Member #2 did not demonstrate adequate knowledge of an individual placed in their care. individual #2 was placed at this address for coverage for approximately one hour during inspection. According to Staff Member's statement, the individual is dropped off at the house for about an hour every weekday while their roommate is taken to day program. When questioned regarding the individual, staff member could not remember the individual's name or any particulars regarding their needs. According to record review, Staff Member #2 did not receive training on the individual's ISP. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | 1) An alternative transportation plan has been implemented for Individual #2 to have appropriate levels of supervision maintained when Individual #2's roommate requires transportation to day program. The plan will ensure they are not left at a site with staff not trained in Individual #2's ISP or conflict with the supervision requirements of other individuals. Target date 11/22/24.
2) The individuals at the complex frequently visit each other, have meals together and staff work in multiple sites. Any time a visit happens, the staff at that site will be trained on care plans and ISPs for all individuals present during the visit. A staff meeting was held where this information was reiterated on 11/20/2024. Target date 11/20/24.
3) Staff 2 received training specific to this individual. Target date 11/20/24.
4) Program Director or designee will ensure annual ISP training is done across sites at the Havertown complex. Target date 1/30/2025 |
01/30/2025
| Not Implemented |
| 6400.163(a) | Probiotic Acidophilus did not have a pharmacy-issued label. The label on the bottle was hand-written. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Original labels on all medication bottles or blister packs is essential for safe medication administration. Pharmacy was contacted and a new label was sent (Attachment #10). The refilled medication blister pack was sent to the site with the correct label (Attachment #11). |
10/17/2024
| Implemented |
| 6400.163(g) | Medications for individual #1 were stored in a disorganized manner -- the medications encompassed three different bins and were not separated by any discernable reason and also contained the medications of individual #3, who has not lived at the address for several months. | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | Medications must be stored in an organized manner. Discontinued or expired medications must be removed from the site to avoid opportunities for medication errors. Individual #3's medications were removed from the site and disposed of according to company procedure on 10/11/24.
Individual #1s medications have been organized and new bins were added to better organize and reduce opportunities for medication administration errors (Attachment #12). |
11/25/2024
| Implemented |
| 6400.163(h) | Two PRN medications for individual #1 were past expiry date: Ibuprofen 600mg tablets (two packages) expired August 2024, Tetrahydrozoline HCL Eye drops (expired September 2024). Two discontinued medications were still present with active medications -- Polyethalene Glycol 3350, Clotrimazole Cream USP 1%. Medicines belonging to individual #3 were still present in the home -- this individual has not lived in the home for several months. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | It is essential that all expired or discontinued medication be promptly removed from the site and destroyed in a safe manner to ensure the health and safety of the residents served and to reduce opportunities for potential medication errors.
Expired and Discontinued medications as well as Individual #3's medications were removed and disposed of on 10/11/24. |
10/11/2024
| Implemented |
| 6400.186 | Individual #1 had 1:1 staff during the visit, then it turned to 1:2 after individual #2 was dropped off. The staffing ratio for individual #1 in the ISP says "CADES WILL PROVIDE individual #1 WITH 24 HOURS OF CARE, 7 DAYS A WEEK. Individual #1 REQUIRES 2:1 STAFFING AT ALL TIMES DUE TO INCREASE MEDICAL AND BEHAVIORAL CONCERNS."
When asked about individual #1's fall risk plan, staff member #2 stated that individual #1 does not have a fall risk plan. Individual #1's ISP states the following: "Individual #1 USES A WHEELCHAIR FOR MOBILITY. Individual #1 IS SUPPORTED WITH A FALL RISK PLAN. Individual #1 NEEDS ASSISTANCE DURING TRANSFERS AND FIRE DRILLS. individual #1 WILL ATTEMPT TO TRANSFER by themself IN/OUT OF their WHEELCHAIR. Individual #1 HAS FELL ON NUMEROUS OCCASIONS TRYING TO INDEPENDENTLY TRANSFER | The home shall implement the individual plan, including revisions. | It is essential that the ISP be implemented as written and is an accurate reflection of the individual's current level of support. CADES failed to advocate for a modification to the supervision language in the ISP for individual 1 resulting in outdated language and information in the ISP. The Program Specialist corresponded with the Supports Coordinator on 11/19/24 regarding the outdated comments in individual 1's plan regarding her ratio, specific to her level of supervision (Attachment #3).
Individual 1 received a new fall risk screening on 12/12/24 (Attachment #13). The fall risk assessment and recommendations from PT were sent to the team for review on 12/13/24. Individual 1 continues to receive ongoing PT services.
Staff #2 was trained on Individual #1's ISP (Attachment #4). |
12/13/2024
| Not Implemented |