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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(e)(12) | Individual #1's current, 2/10/2020 assessment did not include recommendations for specific areas of training, programming and services. The specific field denoted to this within the assessment was left blank. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | This citation was received due to the program manager failing to thoroughly complete the annual assessment.
It is important for all sections of the annual assessment to be completed thoroughly to ensure the team understands how to best support the individual and meet their needs.
Program managers have been retrained on this regulation since the licensing exit meeting with the state licensing team.
Program managers will work with the supervisors of each home to review annual assessments and ensure all sections are of the assessments are entirely completed. If they find that additional information is needed or there are changes that need to be made to the assessment, an addendum will be sent to the individuals team. |
04/14/2021
| Implemented |
| 6400.50(a) | At the time of the 1/4/21 inspection, Staff person #1's training record did not include the content of her trainings, the training source, the trainer and on occasion the length of time the training took to complete. | 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. | Penn-Mar failed to keep on file the content of trainings along with the signature sheets that show the source, dates, and length of training.
This regulation is important to ensure team members are properly trained to support the individuals they are working with and are able to meet their needs.
Program Managers and Supervisors were retrained on the need to ensure all team members review ISPs, protocols, support plans, behavior plans, and assessments prior to working with individuals. A new process was put in place in November 2020 to have Program Managers review weekly training reports for team members that have worked in each program to ensure all team members have completed the training requirements for each program. Weekly audits are also conducted by the Director and Administrator to provide another level of oversight to ensure that staff working have completed all required individual specific training prior to working with individuals.
A new process was put into place in November requiring Managers and Nurses to meet with teams to review protocols together. These meetings are held virtually and recorded. The protocol videos along with a Microsoft Word document of the protocol will then be uploaded into UltiPro (training platform). This will show the content of each protocol training. Protocol trainings include content, dates, length of training and staff persons attending. If team members are unable to attend the team meeting, they are required to review the recorded training at the start of their next shift. New protocols or updated protocols are immediately written and reviewed with team members. See attachment #11 Protocol Training Guide.
For staff training on things such as hospitalization discharge documents, the Learning and Development department will save staff signature sheets with the content they reviewed so they we are able to provide training information when required. See attachment # 12 - in-person training guide. |
04/01/2021
| Implemented |
| 6400.165(c) | Failing to administer the individual's medication as prescribed creates an environment where the individual is susceptible to additional medical problems or concerns created by not having their medications administered to them as prescribed. Individual #1 was assessed to need full support with medication administration and required staff to complete all steps of medication administration for her. Throughout the inspection period reviewed, September 2019 to January 2021, there were multiple occasions where Individual #1's medications were not administered to her as prescribed by her physicians. The following are examples of this:
- On 11/19/20 the individual's physician ordered the individual's multivitamin and Vitamin D3 to be held from administration from 11/23/20-11/30/20. Neither prescribed supplement was held on 11/23/20 or 11/30/20.
- The individual's physician ordered the individual's Dicyclomine to be held from administration on 11/30/20. Staff administered the individual's 8PM dose of Dicyclomine on 11/30/20.
- Individual #1's 4PM dose of Dicyclomine was not administered on 11/25/20 and her 8AM dose of Fluticasone wasn't administered on 8/11/20. On both occasions, staff documented the medications were held due to an event. There are no records maintained from the individual's prescribing physician to hold either administration of Dicyclomine on 11/25/20 or Fluticasone on 8/11/20.
- Individual #1 is prescribed Polyethylene Glycol powder to be administered daily if no bowel movement is produced in 3 days. This medication was not administered as prescribed for almost a year. Examples of when this medication wasn't administered as prescribed are as follows:
· She had a bowel movement on 5/9/20 and not again until 5/17/20. She was administered the medication on 5/11/20 (too soon per orders), and again on 5/13/20 and 5/14/20, which wasn't a daily administration as ordered due to her not producing a bowel movement until 5/17/20.
· She had a bowel movement on 5/5/20 and not again until 5/9/2020, 5/29/20 and not again until 6/3/20, 6/5/20 and not again until 6/10/20, 6/13/20 and not again until 6/17/20, 6/23/20 and not again until 6/29/20, 7/12/20 and not again until 7/19/20, 8/2/20 and not again until 8/9/20, 8/10/20 and not again until 8/16/20, 8/18/20 and not again until 8/23/20, 8/23/20 and not again until 8/28/20, 8/30/20 and not again until 9/3/20, 9/3/20 and not again until 9/7/20, 9/10/20 and not again until 9/14/20, 9/15/20 and not again until 9/22/20, 9/25/20 and not again until 10/1/20, 10/1/20 and not again until 10/5/20, 10/5/20 and not again until 10/11/20, 10/14/20 and not again until 10/20/20 then not again until 10/26/20, 10/27/20 and not again until 11/2/20, 11/5/20 and not again until 11/11/20 then not again until 11/8/20, 11/22/20 and not again until 11/27/20, 11/29/20 and not again until 12/7/20, and 12/23/20 and not again until 12/27/20. For all of these occasions, her medication wasn't administered after the 3rd day of no bowel movement nor was she administered the medication daily after that until a bowel movement was produced.
· She had a bowel movement on 7/23/20 and not again until 7/30/20. She was administered her medication on 7/27/20 however, this was after 4 days without a bowel movement produced and did not follow the prescriber's order. She wasn't administered the medication daily after the 7/27/20 dose, again not following the prescriber's order. | A prescription medication shall be administered as prescribed. | The organization recognizes that the Vitamin D3 and the multivitamin should not have been administered per the physicians order on 11/23/2020 and 11/30/2020. These incidents were medication errors that should have been filed in the EIM system.
Staff administered the individual's 8PM dose of Dicyclomine on 11/30/20 when there was an order to hold the medication. The individual had a colonoscopy on 11/30/2020. Staff administered the medication without the order to resume the medication after the procedure on 11/30/2021.
It is important that medications as prescribed to control medical conditions. When physicians order medications to be held prior to a procedure, its important to follow the order to prevent complications with the procedure.
All individuals that are prescribed a medication to aid in bowel movements or have a history or diagnosis of constipation have bowel charts where staff are to document whether the individual had a bowel movement. The bowel chart tracking form was updated to include each individuals bowel protocol, the Bristol Stool Chart, when the PRN should be given and the time the bowel movement occurred. The new bowel chart was implemented starting February 1, 2021. Supervisors were trained on how to complete the updated form via email on 1/28/2021. The new form was also reviewed with supervisors during a virtual meeting on 2/10/2021. Supervisors have reviewed the updated bowel charts with direct support staff that report directly to them. All direct support reviewed the bowel chart training through our online training system in March. Supervisors are required to review bowel charting during each shift and managers are required to review bowel charts at least weekly to ensure bowel protocols are followed and that documentation is completed thoroughly.
Program managers and nurses received training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of ensuring medication orders are followed.
To ensure this regulation is met, the nurses will thoroughly review MARs to ensure medications administration are documented as required. In addition, program managers will review MARs during monthly monitoring of the home.
All residential team members received training via email regarding this regulation. see attachment #2 -email sent to all residential team members.
A review of this regulation will also be completed with the Residential Supervisors again at their next team meeting on April 14, 2021. |
04/14/2021
| Implemented |
| 6400.167(a)(4) | Individual #1 is prescribed Dicyclomine to be administered at 12PM daily. The home failed to administer the medication at the prescribed time, which exceeded more than 1 hour before or after the prescribed time on the following days: 1/2/20, 1/7/20, 1/9/20, 1/21/20, 1/22/20, 1/27/20, 2/7/20, 2/10/20, 2/11/20, 2/18/20, 2/22/20, 2/24/20, 2/25/20, 3/9/20, 3/10/20, 7/1/20, 7/7/20, 8/4/20, 9/25/20, and 9/29/20. | 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. | On the following dates, 1/2/20, 1/7/20, 1/9/20, 1/21/20, 1/22/20, 1/27/20, 2/7/20, 2/10/20, 2/11/20, 2/18/20, 2/24/20, 3/10/20, 8/4/20 individual #1s Dicyclomine was administered on time with notations that it was given while on outing. On 2/22/20 individual #1s Dicyclomine was administered on time with notation made concerning the computer was not working. See attachment # 29 -Staff notes pulled from the e-MAR system from the day program regarding medication administration 10/2/2019-2/12/2021.
There is no indication why the medication was not administered at the prescribed time on 2/25/20, 3/9/20, 7/1/20, 7/7/20, 9/25/20, and 9/29/20. The organization recognizes that the late documentation of the medication administration could be considered medication errors and should have been filed in the EIM system.
In the Residential Supervisor meeting on February 10, 2021, Residential Supervisors were re-trained on the correct way to document medication administration after the 1 hour window when the prescribed time of the medication has passed. Instructions were to do the following, click other on the electronic medication system, Carasolva, and add a note indicating the reason why the medication prompt was not signed-off by staff within the 1 hour before or after the prescribed time. Residential Supervisors then disseminated this information to their team members within their designated programs.
Program managers and nurses received training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. They understand the importance of ensuring medication orders are followed to ensure the individuals health needs are met.
To ensure this regulation is met, the nurses will thoroughly review MARs to ensure medications administration are documented as required. In addition, program managers will review MARs during monthly monitoring of the home.
All residential team members received training via email regarding this regulation. see attachment #2 - email sent to all residential team members.
A review of this regulation will also be completed with the Residential Supervisors again at their next team meeting on April 14, 2021. |
04/14/2021
| Implemented |
| 6400.167(b) | There are no records maintained that the agency, Penn-Mar Human services, documented the medication errors, follow up action taken, and the prescriber's response to the medication errors described in 6400.165(c) and 6400.167(a)(4) of this report. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | This citation was received because staff failed to document medication administration or administered the medications late on several occasions and the program manager failed to follow up with the staff regarding late administration and file reports if necessary.
It is important to ensure documentation of the medication administration is completed at the time the medication is administered to prevent potential medication errors. If a medication error occurs, it is important for staff to follow up with the prescribing physician and follow their recommendations. It is also important for the manager to provide retraining to the team member that had the medication error. All medication errors are required to be filed in EIM.
All staff will be retrained on the expectation to utilize the paper MAR when they do not have internet access. In addition, all staff will be retrained on how to properly document on the electronic MAR when documentation of a medication administration is written on the paper MAR. see attachment # 3 - medication administration documentation email. All team members administering medication are also required to take a video training created by an agency nurses regarding medication administration documentation by 4/16/2021. See attachment # 4- medication documentation training
Program managers and nurses have had training regarding this regulation during the exit conference with state the state licensing team on January 11, 2021. Program managers will continue to monitor MARs during monthly site monitoring at each group home. Site monitoring completed by Program Managers are monitored monthly for completion by the Community Living Administrator and the Director of PA Program. Effective 3/22/2021, the nurses will start to complete weekly audits of MARs to ensure medications are being administered as ordered. |
04/01/2021
| Implemented |
| 6400.181(f) | Individual #1's current, 2/10/2020 assessment was sent to her team members on 2/10/2020. However, the individual's individual plan meeting was held on 3/4/2020. Her assessment was not sent to the team members at least 30 calendar days prior to her meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The program manager failed to forward the individuals annual assessment 30-days prior to the ISP meeting.
It is important to ensure the annual residential assessment is sent to the team 30-days prior to the meeting so that the team has adequate time to review the updated information prior to the meeting.
Program managers received training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. There have been several conversations with program managers since the state licensing occurred in January regarding citations the agency received. They understand the importance of forwarding the annual assessment to the teams of individuals at least 30-days prior to the ISP meeting date.
A review of this regulation will also be completed with the Residential Supervisors again at their next team meeting on April 14, 2021. |
04/01/2021
| Implemented |
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