| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1's daily progress notes provide detailed instances of individual #1 exhibiting and expressing physical and emotional pain through verbal and nonverbal cues. According to Individual's #1's Individual Support Plan (ISP) the individual has a plan in place for staff members to assist him during times of mental and emotional distress. His ISP reads, " [Individual #1] will, at times, express suicidal ideation or talk down about himself as a way to communicate frustration or depression to staff. Support staff are to provide support when he is upset. Warning signs that [Individual #1] may be having a difficult time is him making negative comments towards himself or others, not wanting to take his medications and showing aggression." Individual #1's Individual Support Plan (ISP) states that he "could become a danger to himself or others if he did not have the daily support to maintain structure and medication compliance."
On 5/14/19, Individual #1's physician added Latuda 20mg in the morning and requested to be contacted any time Individual #1 exhibited signs of increased aggression. Between May and August 2019, Individual #1 displayed the following behaviors, as documented in Individual #1's progress notes by Holcomb staff members:
On 5/26/19 a staff member, who's signature couldn't be identified, wrote "staff asked [Individual #1] to place his dirty clothing in the shoot. The individual began to curse and stated he did not trust putting his clothing in the shoot. He cursed while placing his laundry down the shoot. He cursed for 2 minutes ignoring staff redirection to stop cursing." Individual #1's behavior support plan did not state that staff are to force the individual to perform a task that is upsetting to him without offering any other options to complete the task. The behavior support plan did not state that staff are to continue to force the individual to complete the task once the individual has shown it is upsetting to him. Individual #1 verbally expressed his concern of not trusting the laundry shoot. Staff #1 recorded on 5/27/19 "[Individual #1] was very hidden and seemed sad today" and on 5/31/19 "when I picked up [Individual #1] from program, he seemed more depressed saying "his stomach hurts" and "nobody cares about him here."
Over the next week, staff members continued to record Individual #1's declining mental and physical state. On 6/1/19 Staff #2 wrote "[Individual #1] appeared to be very tired today and he wanted to be left alone." On 6/8/19 Staff #1 wrote "[Individual #1] was very hidden today and only came out to eat and take meds." On 6/9/19, Individual #1 replied "I don't know" and "I don't care" when asked how he was feeling. Staff #1 recorded on 6/21/19 that "[Individual #1] said he wasn't doing good when I asked how he was doing." On 6/24/19, Staff #1 wrote "[Individual #1] before leaving for program seemed to be in a bad mood. I asked how he was doing and wasn't very responsive. He didn't say kind things to other within the house." Another staff documented he refused breakfast. On 7/1/19, Staff #1 recorded "[Individual #1] seemed negative and not happy. He kept making negative comments and saying bad language." Staff #1 recorded on 7/3/19 "[Individual #1] seemed unhappy and irritated. He hasn't been very happy lately." Staff documented that Individual #1's refusals to eat breakfast increased in consistency. He refused breakfast on 7/2/19, 7/3/19, 7/5/19, 7/7/19, and 7/8/19. | 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. | This incident was entered in HCSIS EIM and was assigned to a certified investigator (EIM #8578129). This investigation was completed by the investigator but was rejected by the administrative review for not providing the team adequate information and documentation on this case. An extension was requested in order for the assigned CI to complete the investigation thoroughly and completely. In the interim, all staff were reminded to consistently be on alert for changing medical or psychological conditions with our individuals and not to assume or disregard signs and information they see or that are reported to them. Their roles and responsibilities were reviewed on how to recognize and respond to medical emergencies as an immediate remedy. Once the investigation is finalized if additional remedies are require, they will be put in place. |
09/30/2019
| Not Accepted |
| 6400.16 | Individuals #1's and #2's medications were not administered per physician orders, as detailed in 6400.165, 6400.165(c), and 6400.166(a)(12);(13) on a regular basis to manage the individual's mental and physical health. Individual #1 is prescribed medications for the management of Seizures, Neuroleptic-Parkinson's, Heart Health, Schizoaffective Disorder, and Constipation. Holcomb did not have documentation that Staff #3 and #4, who administered medications to Individuals #1, #2, and #3 for the last year, were certified under the Department's Medication Administration Course to administer medications, as described in 6400.169 and 6400.188(a). Staff #3 reported on 7/16/19, as well as Holcomb reporting medication errors to the Department on 5/19/19, that Individual's #1 and #2 could not receive their prescribed medications on occasion. Staff #3 worked at another community home and traveled to Individual #1 and #2's home to administer medications since medication trained staff were not scheduled to work each shift.
Holcomb failed to ensure medication trained staff were present on each shift to make certain prescribed medications were administered to the occupants of the home. Furthermore, holcomb failed to report medication omissions and/or errors to the individuals' physicians such that follow up recommendations and individuals' health could not be monitored. Finally, Holcomb could not produce documentation that any staff working with Individual #1 received training in the last year on the individual's seizures, how to document seizures, seizure symptoms to look for, or training on the individual's diagnosed disorders of Schizoaffective Disorder and Neuroleptic-Parkinson's disorder.
Staff #4 and the Department's licensing staff witnessed Individual #2's ambulation difficulties during the unannounced fire drill held on the morning on 7/17/19. Individual #2 was unable to ambulate to the end of the driveway, the designated meeting place, and stopped just outside the garage attached to the house. Individual #2 had shaking, bent legs and was holding onto the side of the house for stability. Per Staff #4's report during the fire drill, she was aware of Individual #2's unsteadiness and ambulation difficulties and considered it, "a behavior." Holcomb staff members, with knowledge of Individual #2's ambulatory difficulties, dismissed the ambulatory concerns, and instead deemed it a behavior. Holcomb's failure to seek medical attention or evaluation for Individual #1's ambulatory difficulties constitutes neglect. | 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. | Please reference hard copy of the POC submitted on 10/23/19 located at ODP offices.
Due to the staff shortages in this home medication errors were not reported consistently as required by the Incident Management Bulletin. The House supervisor of the sister home in Lancaster was assigned to oversee the home on a day to day basis (including medications and appointments) in conjunction with the IDD manager. These oversight and recommendations were not followed up on by either of them. Neither of these people are still employed with Holcomb at this time.
The staff report that they are aware of how to recognize and respond to seizures, but no documentation of this specific training could be located. However, all staff are trained on each individual¿s behavior support plan which includes both the medical and psychological diagnosis in them and this information is reviewed at the time of training. Documentation for this training is available.
Individual #2 was assessed and discharged from PT on 8/20/18 and was order to wear compression garments for swelling in the legs. Individual #2 is an older man uses a cane or a rollator walker to ambulate. On this day he chose to use his cane; he does have a rollator walker on site and available for his use at all times. When the inspectors made Director of IDD services aware of the above noted occurrence, Individual #2 was offered his walker and encouraged to use it moving forward. While he is encouraged to, Individual #2 often times is not compliant with wearing his compression garments on his legs. A follow up evaluation for this individual is scheduled to determine if there are any other recommendations to improve his ambulation. |
09/30/2019
| Not Accepted |
| 6400.16 | On 07/16/19, Individual #2 disclosed that his left eye had been bothering him for a few days. The eye appeared red and puffy. Individual #2 stated that he told Staff #3 about his eye problem and was told that an eye appointment had been scheduled. On 07/17/19 Individual #2, again, stated that his eye was hurting him. It still appeared red and puffy. Staff #3 then stated, "[Individual #2] makes things up and no appointment has been scheduled." Licensing staff directed the agency staff to make a doctor's appointment for Individual #2 so that his eye could be examined, since the agency's staff did not take the initiative to contact a medical professional. Individual #2 saw his primary care physician on the evening of 7/17/19. He was diagnosed with Left Eye Conjunctivitis. The treatment summary form reads, "[Individual #2] has pink eye in left eye. Staff took prescription to 24-hour pharmacy". Holcomb's dismissal of Individual #2's eye pain and continual failure to obtain prompt medical treatment placed Individual #1, #3 and staff working in the home at risk of contracting Conjunctivitis, a highly contagious medical condition. Failure to seek medical attention and unnecessary exposure to a contagious medical condition constitutes neglect.
Licensing Staff reviewed Individual #1's medications during the physical site inspection. The medication label for Individual #1's medication, Linzess, states the medication was dispensed on 6/2/19. The entire 30-day supply of pills were contained in the pill packet. The individual also had a current physician's order from July 2019 stating Linzess was to be administered daily. This medication was available in the home and the staff were not administering the medication.
Individual #1's 8PM medication 30-day supply packets for Amantadine, Ducosate, fiber lax, Lithium Carbonate, Oxcarbazepine, Propranolol, Simvastatin, and Trazodone contained a medication label that stated the medications were dispensed on 6/2/19 and only 17 pills of the 30-day supply were popped out. The medication label for the individual's Clozapine states it was dispensed on 6/25/19 and only 20 pills were popped out of the 30-day pill supply. The medication label for the Individual #1's 8 AM medications, vitamin D3, Oxcarbazepine, Propranolol, Levothyroxine, fiber lax, Chlorpromazine, Amantadine and Aspirin stated they were dispensed on 6/2/19 and only 18 pills from the 30-day supply were popped out of the packet. The medication label for the individual's 8AM medication Latuda stated it was dispensed on 6/24/19 and only 18 pills were popped from the 30-day supply pill packet. All pharmacy records for Individual #1 relating to the medications dispensed, amount of medication dispensed, and date dispensed was requested from the provider on 7/18/19. Holcomb did not provide this information to the Department. According to the dispensed date on the medication labels for Individual #1's medications, most, if not all, of the medications should have been popped out of the pill packets and administered to the individual by the time of the inspection on 7/18/19. There were medication logs for June and July 2019. However, the only medications available to administer to the individual were dispensed on 6/2/19, 6/25/19, etc. (as listed above). If they were administered correctly, after the dispense date from the pharmacy, most of the medications should have been administered and empty from the pill packets. There were medications left in some pill packets that should have been empty. The agency was unable to provide the pharmacy dispense records to show that medications were available in the home to administer for the last few months. | 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. | This incident was entered in HCSIS EIM and was assigned to a certified investigator (EIM #8577903). This investigation was started but has not been finalized in EIM due to a conflict of the CI being a witness and apart of the investigation. An extension was requested in order for a co-investigator to take over and to complete the investigation thoroughly and completely. In the interim, all staff were reminded to consistently be on alert for changing medical or psychological conditions with our individuals and not to assume or disregard signs and information they see or that are reported to them. Their roles and responsibilities were reviewed on how to recognize and respond to medical emergencies as an immediate remedy. Additionally, staff person #3 was suspended for this and other infractions and has not returned to work. Additional personnel actions to follow. Once the investigation is finalized if additional remedies are require, they will be put in place.
Upon review Doctor visit forms for Individual #1, he was prescribed Linzess by his PCP. There was no record of this medication being discontinued in the home. Follow up calls were made to the PCP and they had no record of the medication being discontinued either. Based on this, it was determined to be a medication error. The Linzess medication was relisted on the MAR to be administered. While a medication error is not a mandatory investigation, this incident is being heavily researched to determine who discontinued the medication on the MAR and when.
A medication Audit was done on all of the medication in the home and it was found that the medication in the blister packs did not correspond with the calendar date for the amount of medication that would be missing from the pack had that pack been started at the beginning of the month. By examining the medication log it is noted that the staff dispense the medication but do not write the number of pills remaining of the medication on log. In doing staff interviews, it was reported by multiple staff that the pill count has not been in line with the calendar for some time now. They say that they typically start the new month¿s blister pack before the new month actually starts. In reviewing the med logs, the medication is signed off on daily for the previous months documenting that the medication was indeed given. Due to the management vacancies, Staff # 3 was the supervisor of the sister home in that area and was assigned to review the medications in this home on a routine basis, clearly this was not done. Staff person #3 was suspended for this and other infractions on 7/19/19 and has not returned to work. Appropriate personnel actions taken to address the above occurrence.
As a remedy, a complete medication audit will be conducted again to review all medication, all physician¿s orders and to reconcile the med count. Staff will be retrained on how to document medications counts on the log in addition to signing for the medication given. Staff will also be retrained on how to properly report and document a medication error. Going forward medications will be reviewed in this home weekly by the House Manager or IDD Coordinator or their designee.
The allegation of Abuse for the failure to provide prescribed adequate care will be entering into HCSIS EIM and assigned to a CI. |
09/30/2019
| Not Accepted |
| 6400.16 | Individual #1 consistently exhibited significant mental health symptoms for a period of two months. Staff failed to use the behavior support plan to support Individual #1 during times of distress. There is no evidence to show Holcomb staff contacted a medical professional, as requested on 5/14/19 by Individual #1's physician when Individual #1 displayed significant mental health symptoms and reported complaints of pain. Failure to seek medical attention and follow physician orders such that Individual #1's mental health steadily declined constitutes psychological abuse and neglect.
On 7/8/19 Staff #1 documented "[Individual #1] came home early from program because he was complaining of side pain and he had trouble walking. [Individual #1] did well with responding when I said he had to come with me to pick up his housemate." After the staff's visual inspection of the individual's inability to walk at their typical ambulation level and documenting her concern, medical attention was not sought until 7/9/19. According to the summary report from Dr. William Roberts, the agency did not seek medical treatment for Individual #1's complaints of pain and inability to walk. Medical treatment was not sought until 24 hours after staff witnessed and documented the individual's physical health declining to the extent that the individual, who was previously ambulatory without concern, was now unable to ambulate without concern.
On 7/9/19, Dr. William Roberts prescribed Doxycycline Hclate (Vibramycin) 100mg capsule, 1 cap by mouth 2 times daily with meals, for 10 days for a diagnosis of Bronchitis. According to the summary report, the medication was to be administered beginning on 7/10/19. According to the Individual #1's medication administration record, Doxycycline 100mg was not administered until 8pm on 7/11/19, 24 hours after the doctor's order to start administering the medication. | 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. | This incident was entered in HCSIS EIM and was assigned to a certified investigator (EIM #8578134). This investigation was completed by the investigator but was rejected by the administrative review for not providing the team adequate information and documentation on this case. An extension was put requested in order for the assigned CI to complete the investigation thoroughly and completely. In the interim, all staff were reminded to consistently be on alert for changing medical or psychological conditions with our individuals and not to assume or disregard signs and information they see or that are reported to them. Their roles and responsibilities were reviewed on how to recognize and respond to medical emergencies as an immediate remedy. Once the investigation is finalized if additional remedies are require, they will be put in place. |
08/30/2019
| Not Accepted |
| 6400.22(a) | Individual #2 is assessed to require assistance with financial management. Holcomb is designated to be the individual's representative payee and is responsible for assisting the individual with support in acquisition, maintenance and improvement of their financial affairs. Individual #2's record included an email from previous Holcomb CEO, Staff #6, to Staff #7 on April 29, 2019 stating "Social Security stopped the individual's payment due to Rep Payee forms not being received timely per a phone call made by previous Holcomb Staff #8 and I in January. We contacted our fiscal dept about this - the Rep Payee form was completed and forwarded to SS by Chimes. Staff #8 and I were advised, per the SS representative we spoke with in January, to follow up with the local office in Lancaster to rectify this. When I spoke to her about this recently she had not yet gone to the local office."
The agency failed to perform their duties of ensuring the individual's financial needs and access to funds were maintained from January 2019 until April 2019. At the time of the inspection on 7/16/19, residential staff was unsure if the individual's access to funds and financial needs had been reinstated.
A written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property was requested during the 7/16/19-7/18/19 onsite inspection. This policy was never submitted to licensing. | There shall be a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property. | IDD Manager has been working with Individual #2 to ensure individual's financial needs and access to funds are maintained. Individual #2's finances have been reinstated. A meeting with Holcomb's parents company's (Chimes) Client Accounts Manager, Bernadette Baskerville, has been requested to review representative payee concerns and monitoring. A written policy regarding individuals' funds was requested from Chimes. |
08/30/2019
| Not Accepted |
| 6400.22(c) | A purchase order (k132761510) from Peapod (Giant foods) indicates that a delivery of grocery items to 3112 Cochran Drive occurred on 07/15/19 which included four, Arm and Hammer, 2 in 1 Laundry detergent power packs, clean burst scent. Each package of Arm and Hammer detergent contained 21 individual packets of laundry detergent pods, for a total of 84 laundry pods being delivered. One pod is to be used during each load of laundry.
During a morning site inspection on 07/18/19 at 5740 Main Street, East Petersburg, Staff #9 from Cochran Drive contacted house supervisor Staff #3, who was at the Main Street residence, to request laundry detergent as there was "none at the Cochran drive residence." Three days prior to this phone call, 84 laundry pods were delivered to Cochran Drive. Upon site inspection back at Cochran drive, there was no laundry detergent found by a licensing representative. The individual's pay room and board to the agency monthly that is to cover items such as laundry detergent to be shared at the home. Room and board money was used to purchase 84 laundry pods 3 days prior to the unannounced inspection. 84 loads of laundry were not completed in 3 total days at the home. Therefore, the individual's funds used to purchase the laundry pods, were not used solely for the individuals' benefit as the pods are missing from the home. | Individual funds and property shall be used for the individual's benefit. | Inventory sheets are being developed for each residents' belongings and house hold goods to track usage of items and necessity for purchasing. Staff will be responsible for documenting usage via signature. IDD Supervisor and Coordinator will review inventory lists weekly. |
08/19/2019
| Not Accepted |
| 6400.32 | As referenced in this report under 6400.16, 6400.34(a), 6400.33(d), and 6400.33(f) Individuals #1 and #2 were deprived of their rights listed under 6400.33. | An individual may not be deprived of rights.
| Allegations are currently under review. Appropriate actions are being followed, including entering incidents into EIM. |
08/30/2019
| Not Accepted |
| 6400.33(d) | During the onsite inspection on 7/16/19-7/18/19, Staff #9 stated that the individuals living in Cochran Drive are not given the opportunity to participate in menu planning and program planning that affects their daily meals, snacks offered and food available in the home. Per discussion with Staff #9, the home does not have menus available at the home where the individuals can provide input of meals they would like to eat. Staff #9 stated that a menu book is available at the home that includes recipes to make as meals. However, Staff #9 stated that the individual's in the home do not like the recipes in the menu book.
Per Individual #2 on 7/16/19, he reports that he stays in his house every day and only goes out into the community with a paid staff who is provided by a different agency. There is no documentation to indicate that Individual #2 was provided opportunities for community outings or community outings of his choice.
Staff #3 confirmed on 7/16/19 that the individual's do not go into the community due to the lack of staff provided by the Holcomb agency. During the inspection, Individual's #1 and #2 fell asleep sitting in chairs in the staff area, due to no community outings being completed, and no in-home programming being provided to them. Staff was not interacting with the individuals or attempting to engage in home programming, preventing the individuals from being so bored, they fell asleep. | An individual has the right to participate in program planning that affects the individual. | All allegations of rights violations are being addressed. IDD Director and Director of Operations addressed staff needs to encourage resident participation in community outings and social engagement. Each week since then, the grocery list has been created based on the requests of both individuals. Menus have been created in collaboration with residents, noting residents¿ preferred food items and shopping lists are developed based on the menu. |
07/18/2019
| Not Accepted |
| 6400.33(f) | Holcomb serves as Individual #2's representative payee and is required to ensure he receives monthly funds so that he can receive, purchase, have and use personal property.
Individual #2's record contained an email dated April 29, 2019 from previous agency CEO, Staff #6, to fiscal Staff #7, stating "Social Security stopped the individual's payment due to Rep Payee forms not being received timely per a phone call made by [Staff #8] and [Staff #6] in January. We contacted our fiscal Department about this - the Rep Payee form was completed and forwarded to SS (social security) by Chimes, the parent company. [Staff #8] and [Staff #6] were advised, per the SS representative we spoke with in January, to follow up with the local office in Lancaster to rectify this. When [Staff #6] spoke to [Staff #8] about this recently she had not yet gone to the local office."
At the time of the inspection, Holcomb did not know if Individual #2's funds had been reinstated. From January 2019 until April 29, 2019 Holcomb was aware that Individual #2's funds had been terminated and did not attempt to rectify the situation for a minimum of 4 months. | An individual has the right to receive, purchase, have and use personal property. | During this time, Holcomb BHs was transitioned to Chimes International (Parent Company). During this transition there was a lag in filing the paperwork for redetermination for Individual #2 Social Security Funds. According to documents, Chimes International completed and submitted Individual #2 financial situation to the Social Security office on 2/28/19. According to his financial statement funds were reinstated in May 2019 and he received a large payment of $6014.00 which posted on May 1, 2019. Since this time a designated person in Chimes (Account Manager BB) handles all redetermination paperwork to be filed with Social Security. The papers are received in Holcomb's main office in Exton and then scanned and emailed to a specified person in Chimes and the paperwork is completed and submitted. Since this incident, there have been no further incidents of delayed paperwork filing or clients losing funding. |
08/01/2019
| Not Accepted |
| 6400.46(g) | Staff #3 and #4 received training by a fire safety expert in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department on 3/24/18 and not again until 6/29/19. This is outside the annual time frame requirement.
Staff #3 also works primarily out of another residential home location. She only received fire safety training and its contents described above for the Cochran Drive location. She did not receive the training specific to the other residential location as well. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). | An audit of all personnel files was conducted on 07/31/2019 to review certification and training needs. All staff will receive site-focused Fire Training by 08/12/2019 by IDD Director or designee. Fire Safety training will be held on site moving forward. |
08/12/2019
| Not Accepted |
| 6400.46(i) | Staff #4 received Cardio-Pulmonary Resuscitation (CPR), first aid and Heimlich training by a certified trainer on 6/30/18. At the time of the inspection on 7/16/19, Staff #4 only received training in CPR and AED on 5/16/19 annually. There's no documentation that she received first aid and Heimlich training annually as required. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | An audit of all personnel files was conducted on 07/31/2019 to review certification and training needs. All staff will receive CPR, First Aid, and Heimlich training. Moving forward, staff not in compliance will be removed from scheduling. |
08/30/2019
| Not Accepted |
| 6400.61(a) | Staff #4 and the Department's licensing staff witnessed Individual #2's ambulation difficulties during the unannounced fire drill held on the morning on 7/17/19. Individual #2 was unable to ambulate to the end of the driveway, the designated meeting place, and stopped just outside the garage attached to the house. Individual #2 had shaking, bent legs and was holding onto the side of the house for stability. Per Staff #4's report during the fire drill, she was aware of Individual #2's unsteadiness and ambulation difficulties and considered it, "a behavior." Holcomb's staff members, with knowledge of Individual #2's ambulatory difficulties, dismissed the ambulatory concerns, and instead deemed it a behavior. Holcomb's failed to seek medical attention or evaluation for Individual #1's ambulatory difficulties. | A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. | Individual #2 is an older man uses a cane or a rollator walker to ambulate. On this day he chose to use his cane; he does have a rollator walker on site and available for his use at all times. When the inspectors made Director of IDD services aware of the above noted occurrence, Individual #2 was offered his walker and encouraged to use it moving forward. Staff person #4 is aware of this and we are unsure why she responded to this situation in this manner. Staff person #4 was address about this and for other and other infractions on 7/23/19. Appropriate personnel actions taken to address the above occurrence. |
07/23/2019
| Not Accepted |
| 6400.64(a) | Individuals #2 and #3 share the stand-up bathtub in the hallway bathroom. There was a green, used, bar of soap located sitting on the ledge of the standup bathtub. The bar of soap was not kept in a labeled, covered container indicating who's bar of soap it was.
Individual #3's bedroom had a strong smell of urine. The urine odor could be smelled upon entering the home from the front door entrance. The front door is approximately 15 feet from the individual's bedroom door.
The hallway bathroom had a pungent smell of urine, feces and body odor. This could also be smelled upon entry to the home via the front door as well. The bathroom door is approximately 15 feet from the front door entrance also. The bathroom contained a laundry shoot that led to the downstairs laundry room. The laundry shoot had an open top and no closing mechanism, like a dog-door would have. Located on all walls inside the laundry shoot in the bathroom and down the inside of the entire length of the shoot, was brown smears stuck on the walls.
Individual #1's bedroom had two, quarter-sized, brown spots by his bed headboard and side of his bed by his nightstand and tv.
Individual #1's bathroom walls are covered with brown spots, stains, and drips over every wall.
Individual #1's sliding, glass shower doors were almost completely white with white water residue. | Clean and sanitary conditions shall be maintained in the home. | Maintenance staff, Earle Williams and Walt Taylor, had been assigned to clean the laundry chute, bathrooms, walls and flooring. Personal hygiene items have been contained and labeled according to ownership. Staff have been retrained on maintaining a sanitary home environment. Staff assist residents in maintaining common living skills, including cleaning. Staff will follow up after residents to ensure a clean, sanitized home. A monthly checklist has been developed to support in monitoring completion of tasks. A cleaning service had been contacted for a deep clean of the home, with a consultation scheduled for 08/06/2019. |
08/19/2019
| Not Accepted |
| 6400.66 | The light in Individual #1's ceiling fan and outside of his shower was not operable at the time of the inspection on 7/17/19. Four out of the seven lights above the mirror in the main hallway bathroom were not operable. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Facilities arrived on 7/18/19 and replaced all non-working bulbs. Staff was re-trained to maintain light bulbs in the home so that broken or non-working bulbs could be replaced immediately. Administration will check for non-working bulbs at every site visit, and IDD Coordinator will ensure bulbs are working daily. |
08/05/2019
| Not Accepted |
| 6400.67(a) | The baseboard heater in Individual #1's bathroom contained rust over the entire heater. There was a hole, approximately 1-2 inches in diameter, located by the individual's toilet paper holder that is not painted or patched with drywall. The hole was filled in with a rubbery-type substance. The individual's bathroom had a crack and peeling paint above his shower walls, exposing unfinished drywall underneath. Approximately a 10-foot-long by 6 inch wide piece of wall behind the individual's oversized chair in his room was scuffed, had peeling paint, and some brown spots. | Floors, walls, ceilings and other surfaces shall be in good repair. | Maintenance staff, Earle Williams and Walt Taylor, completed remediation or rust on base heaters and painted over the area. Holes and cracks in the walls of the bathroom were patched and painted. A plastic board was installed and painted behind the chair for damage protection. |
08/02/2019
| Not Accepted |
| 6400.67(b) | Individuals #1 and #2 were utilizing walkers and a cane at all times throughout the home to assist with their ambulation. During the inspection, Individual #2 stated he wished he had a rolling walker to help him ambulate better. He also stated he was afraid he was going to slip and fall in the hallway bathroom that he uses and that the bathmat slides.
There is a silver plush carpet, approximately 1 ½ x 3 feet, in the bathroom which slides when stepped on. This is a tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Individual #2 was provided with a rolling walker for support in ambulation. The silver plush carpet was removed and the floor is cleared of tripping hazards. |
07/18/2019
| Not Accepted |
| 6400.82(f) | Individual #1's bathroom did not have individual clean paper or cloth towels. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | This is an individual bathroom so a hand towel would suffice. Paper towels were put in the bathroom the next day. The home including the bathrooms are checked daily to make sure that there is clean paper towel or a hand towel in there daily. |
08/05/2019
| Not Accepted |
| 6400.103 | REPEAT from 1/31/19 annual inspection: The emergency evacuation plan in Individual #1's record does not include the means of transportation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Means of transportation will be added to the emergency evac plan |
08/16/2019
| Not Accepted |
| 6400.104 | There is no indication on a fire notification letter and the date it was sent to the fire department to notify them of the changing needs of the individuals in the home. Individuals #2 and #3 require assistance of walkers and canes to evacuate the home and Individual #3 requires strobe lights due to a hearing deficit. There was a letter to the fire department in the fire drill book, however it did not include a date, the individual's needs or the location of their bedrooms. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| IDD Director will send a fire notification letter with date to the local fire department indicating needs of individuals in the home (i.e. ambulation and hearing deficits), along with bedroom locations. Updated letters will be sent out as needed when new resident needs emerge. Staff will be trained in monitoring resident needs for evacuation support, notifying IDD Supervisor, Coordinator, and/or designee who will update resident information and provide notification to IDD Director for support in updating/ notification to local fire department. |
08/19/2019
| Not Accepted |
| 6400.110(f) | Individual #3 wears hearing aids daily and has a hearing deficit. A letter compiled by previous Holcomb Staff 10 was found in the home's fire drill record book dating back to 2015. This letter stated that the home took the recommendation of the fire department in 2015 to add strobes to Individual #3's bedroom due to his lack of hearing.
During the fire drill on 7/17/19, the strobe light in the main hallway of the home was not operable. This strobe light was the only strobe light in any main area of the home. Therefore, there was not an operable strobe light in the kitchen, living room, or staff area that was operable and would alert the individual in the event of a fire. The Individual's bathroom in the hallway that he uses without staff supervision, was not equipped with a strobe light to alert him in the event of a fire. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | Facilities has contracted with Kisler and Brian to install fire detector strobe light in the bathroom, kitchen, living room, and office. They will also install a bed alarm. The bedroom strobe light continues to work. |
08/30/2019
| Not Accepted |
| 6400.111(a) | The home had seasonal decorations and items stored in the attic of the home. A fire extinguisher for the home was not located at the attic level. It was found on the first step leading up into the attic, on the first floor level of the home. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | All items were removed from the attic on 07/18/2019 and the door has been screwed shut making it inaccessible. |
08/05/2019
| Not Accepted |
| 6400.112(a) | The last fire drill in the record was held on 04/27/19. An unannounced fire drill was not held during the months of May 2019 or June 2019. | An unannounced fire drill shall be held at least once a month. | The supervisor was required to conduct monthly fire drills according to 6400 regulations. This did not occur. Staff #1 was responsible for EOC review and for conducting monthly fire drills. Staff #1 is currently on suspension and personnel action is to follow. A third-shift unannounced fire drill was conducted on 7/24/2019 by the IDD Director; residents successfully evacuated. Unannounced fire drills will be conducted monthly by IDD Supervisor or designee and paperwork related to fire drills will be reviewed by IDD Director to be certain that fire drills occur as required and documentation is complete. |
08/05/2019
| Not Accepted |
| 6400.112(c) | There is no documentation that all smoke detectors were checked to be operable on the following fire drill dates: 01/12/19, 02/12/19, 03/04/19 and 04/27/19. These drills only indicated that the detector set off was operable, not that every smoke detector in the home including the basement and attic was checked for operability. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | All smoke detectors were checked to be operable on 7/24/19. Coordinator will check smoke detectors with each EOC review monthly. EOC review will be submitted to EOC committee and also to IDD Director. |
08/05/2019
| Not Accepted |
| 6400.112(e) | At the time of the inspection on 7/16/19, there was a fire drill held during sleeping hours on 09/23/18 and not again since then. This does not meet the time-line requirement of completing a drill during sleeping hours every 6 months. | A fire drill shall be held during sleeping hours at least every 6 months. | This finding occurred during a lapse in staffing for program Coordinator. A fire drill was held during sleeping hours on 7/24/19. Coordinator will provide reports to IDD Director with log of all fire drills each month. IDD Director will ensure fire drills are held during sleeping hours every 6 months. If there is an absence in IDD Coordinator moving forward, IDD Manager or IDD Director will ensure fire drills are held monthly and during sleeping hours every 6 months. |
08/05/2019
| Not Accepted |
| 6400.113(a) | Individuals #1 and #2's training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building, and smoking safety procedures was completed on 3/24/18 and not again until 5/7/19; outside the annual regulatory time frame. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Individuals #1 and #2 were trained in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting plan outside the building and smoking safety procedures on 5/7/19. Next annual training is scheduled for 5/1/20. |
08/05/2019
| Not Accepted |
| 6400.141(a) | REPEAT from 1/31/19 annual inspection: The most recent physical examination contained within Individual #2's record is dated 08/15/17. There is no documentation that a physical examination occurred annually. A more recent physical examination was requested during the onsite inspection from 7/16/19-7/18/19 but not provided. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | All medical delinquent and outstanding medical appointments will be completed within the month of August. |
09/01/2019
| Not Accepted |
| 6400.141(c)(1) | Individual #1's current 10/19/18 physical examination form did not include a review of his previous medical history. Per the individual's physician's orders, the individual is diagnosed with Schizoaffective d/o, Hypothyroidism, Hyperlipidemia, Constipation, hx-diabetes, Bipolar, Neuroleptic-Parkinson's disease, heart health concerns, Seizure, IBS (Irritable Bowel Syndrome), and takes a vitamin supplement. This information was not contained on his physical examination form. | The physical examination shall include: A review of previous medical history. | The physical examination form was updated to include review of previous medical history. Staff will be trained to be certain that this section of the form is completed for each individual during physical examination. Coordinator will review records monthly to assure that this section is complete. |
08/19/2019
| Not Accepted |
| 6400.141(c)(3) | Individual #1's current 10/19/18 physical examination form did not include a list of his immunizations and screening tests as recommended by the Centers for Disease Control. This information and section was missing from the document. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The physical examination form was updated to include review of previous medical history. Staff will be trained to be certain that this section of the form is completed for each individual during physical examination. Coordinator will review records monthly to assure that this section is complete. |
08/19/2019
| Not Accepted |
| 6400.141(c)(4) | Individual #1's current 10/19/18 physical examination form did not include a vision and hearing screening. This information and section was missing from the document. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | All staff will be trained to check the forms for completion before leaving the doctor's office from a appointment. These forms will be submitted to the Supervisor who will check for completion again. If something is not completed, the supervisor will follow up before submitting to the Coordinator. |
08/30/2019
| Not Accepted |
| 6400.141(c)(6) | Individual #1's current 10/19/18 physical examination form did not include a Tuberculin skin test with negative results or an initial chest x-ray with results noted. This information and section was missing from the document. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The physical examination form was updated to include review of previous medical history. Staff will be trained to be certain that this section of the form is completed for each individual during physical examination. Coordinator will review records monthly to assure that this section is complete. |
08/05/2019
| Not Accepted |
| 6400.141(c)(10) | Individual #1's current 10/19/18 physical examination form did not include if the individual was free from communicable diseases or the specific precautions that must be taken if the individual has a communicable disease to prevent spread of the disease to other individuals. This information and section was missing from the document. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | The physical examination form was updated to include review of previous medical history. Staff will be trained to be certain that this section of the form is completed for each individual during physical examination. Coordinator will review records monthly to assure that this section is complete. |
08/19/2019
| Not Accepted |
| 6400.141(c)(13) | Individual #1's current 10/19/18 physical examination form did not include a list of his allergies or contraindicated medications. This information and section was missing from the document. | The physical examination shall include: Allergies or contraindicated medications. | The physical examination form was updated to include review of previous medical history. Staff will be trained to be certain that this section of the form is completed for each individual during physical examination. Coordinator will review records monthly to assure that this section is complete. |
08/19/2019
| Not Accepted |
| 6400.141(c)(14) | REPEAT from 1/1/19 annual inspection: Individual #1's current 10/19/18 physical examination form did not include medical information pertinent to diagnosis and treatment in case of an emergency. This information and section was missing from the document. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination form was updated to include review of previous medical history. Staff will be trained to be certain that this section of the form is completed for each individual during physical examination. Coordinator will review records monthly to assure that this section is complete. |
08/19/2019
| Not Accepted |
| 6400.142(e) | Individual #1's 8/28/17 dental cleaning appointment record stated, "Recommend sc/rp all quads if insurance will pay for it. Return 2/18." The individual's 3/5/19 dental exam appointment form stated, "filling needed ASAP." The Individual's 3/26/19 dental cleaning appointment record stated he "needs scaling/ root planning -- we will re-scal" and "recommendations: #19 extraction, 13-mors-filling and sc/rp all quadrants" that was needed under anesthesia. A 4/2/19 note in the record from the individual's Gateway Health insurance confirming "your request for a dental benefit limit exception of 4/8/19 for scaling and root planning -lower left, lower right, upper left and upper right is approved as of 4/8/19 until 6/7/19 as long as you continue to have active gateway health dental coverage." As of 7/16/19, the individual had not received follow up dental work regarding the cleaning and scaling under anesthesia, as recommended from 8/28/17. Also, Individual #1 did not have a follow up dental cleaning appointment in February 2018 as recommended. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | Client # 1 was recommended to have dental follow up. Shortly after the insurance approval this home lost both the IDD Coordinator and the House supervisor. The House supervisor of the sister home in Lancaster was assigned to oversee the home on a day to day basis in conjunction with the IDD manager. These recommendations were not followed up on by either of them. Neither of these people are still employed with Holcomb at this time. A Dental appointment for individual #1 was scheduled in July but the first available appointment is on October 9, 2019. In an effort to get a sooner appointment, Individual #1 was place on the ¿Quick Call list¿ for the dental office and he will be called in to fill an open slot of a cancelation. This record and all others will be maintained going forward to ensure adequate follow up by the IDD Coordinator or their designee. Routine chart audits will be performed by the Coordinator, Manager and the Compliance department to ensure that these and all documents are current on the charts. |
08/12/2019
| Not Accepted |
| 6400.142(f) | Individual #1's current 3/26/19 oral hygiene plan and Individual Support Plan (ISP) states that his dentist recommends that he brush, floss and rinse his mouth twice a day for dental hygiene. The oral hygiene plan is typed on a piece of printer paper with a Holcomb Behavioral Health Systems heading. However, according to daily documentation for the last three months, May, June and July 2019, residential staff record on a daily basis, that the individual required staff hand-over-hand assistance to brush his teeth. The individual's dentist recorded on 3/26/19 dental visit summary form "dispensed 2 min timer to brush with" and his 8/28/17 dental appointment stated to "rinse with act or act-like mouth rinse." Individual #1 does not have a dental plan that accurately depicts his dental hygiene needs or includes the dentist recommendations for equipment and mouth wash to be used to complete proper oral hygiene care. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | A Dental plan will developed and all staff will be trained in order to maintain dental hygiene goals. |
08/19/2019
| Not Accepted |
| 6400.144 | REPEAT from 1/31/19 annual inspection: There are numerous occasions in Individual #1's record, where the agency failed to ensure the individual's health services, such as medical, nursing, pharmaceutical, dental, dietary, podiatry, optometry, hematology, blood work and psychological services that are prescribed for were arranged for or provided. For all the occasions, there is no documentation indicating that the individual refused to attend an appointment or comply with doctor's orders, or a reasoning for a late appointment. Below are some of the examples found within Individual #1's record.
· Individual #1's Primary Cary Physician (pcp), Dr. Brian Sullivan, recorded on the individual's 10/19/18 annual physical examination form that the individual is to "check labs: CMP, lipid panel, glycohemoglobia, TSH." CMP tests the individual's Comprehensive Metabolic Panel. TSH is completed to determine Thyroid gland functioning. Lipid panel measures the individual's triglycerides and cholesterol level. Glycohemoglobia is completed to test the individual's glucose levels. At the time of the inspection on 7/16/19, there is no documentation that Individual #1 ever received lab work to check his CMP, Lipid panel, Glycohemoglobia or TSH.
· CRNP (Certified Registered Nurse Practitioner) Deb Hartman requested on 1/9/19 that Individual #1 complete hematology laboratory (lab) work "every 4 weeks and prn (Pro Re Nata or as needed)" for "CBC with diff." CBC with diff stands for Complete Blood County with Differential and is used to measure hemoglobin and hematocrit levels in the individual's system. Individual #1's record does not include information that he had CBC with diff completed or his results in January 2019, results from his 3/26/19 lab work, results from diff lab from 5/14/19, or any lab work completed in June or July 2019 as requested by his CRNP.
· Individual #1's podiatrist indicated on 8/4/17 that he is to continue with follow up appointments every 9-12 weeks. The next appointment in the individual's record was not completed until 4/3/19, almost 2 years later. There is no documentation of the individual refusing these routine appointments in his record or documentation indicating a reason why the appointment was so late.
· Individual #1's current July 2019 physician's orders in his record from Dr. Sullivan, state that the individual is prescribed Linzess cap 145 mcg take daily. According to the individual's medication administration record (mar), this medication hasn't been administered since 12/4/18. There was a 30-day supply of Linzess 145mcg capsules at the home dispensed from the pharmacy on 6/2/19. None of the pills were popped out, nor documented as being administered per the doctor's order.
page 1. (continued on next page) | 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.
| All medical appointments are being scheduled for the month of August. Any follow up treatments and recommendations will be implemented upon return from the visit.
Staff will be retrained on the importance of follow up of medical care for the clients. Medical appointments will be monitored by the coordinator monthly and the Manager and Director Quarterly. |
09/01/2019
| Not Accepted |
| 6400.144 | page 2, continued.
·Individual #1's podiatrist indicated on the individual's 6/5/19 podiatrist appointment form, that the individual should "powder between toes". There is no documentation of medical clarification of the type of powder to be used or how often the individual is to complete this medical recommendation. There is also no documentation that this is being done. The agency Staff #3 confirmed there is never any documentation completed by the agency to show that the individuals comply, or refuse to comply, with doctor's recommendations.
· Individual #1's CRNP Deb Hartman recorded on the individual's most recent 5/14/19 psychiatric medication review, that the individual was to have an increase in Latuda and "call me with any increase agitation." After this appointment, staff recorded multiple times where the individual had increased agitation, however there is no documentation that the individual's CRNP was notified. Some examples of recorded agitation for Individual #1 includes: On 7/7/19 "Individual #1 made negative comments when asked to change his clothes," on 7/6/19 "Individual #1 made negative comments and cursed when he was requested to clean after himself," on 5/29/19 "Individual #1 made negative comments," on 5/26/19 during the 8AM-4PM shift "staff asked (the individual) to place his dirty clothing in the shoot. The individual began to curse and state he did not trust putting his clothing in the shoot. He cursed for 2 minutes ignoring staff redirection to stop cursing" and during the 4PM-12AM shift "he made negative comments at some point and got agitated because staff asked him to change his shirt," on 5/24/19 during the 4PM to 12AM shift "Individual #1 was cursing and talking bad about his roommate," "He even told staff to shut up" and "he went on cursing," on 5/22/19 "he cursed and called his house mate names," and on 5/21/19 "Individual #1 didn't use nice language."
· Individual #1's 8/28/17 dental appointment record stated, "Recommend sc/rp all quads if insurance will pay for it. Return 2/18." The individual's 3/5/19 dental appointment form stated, "filling needed ASAP." The Individual's 3/26/19 dental appointment record stated he "needs scaling/ root planning -- we will re-scal" and "recommendations: #19 extraction, 13-mors-filling and sc/rp all quadrants" that was needed under anesthesia. There is a 4/2/19 note in the record from the individual's Gateway Health insurance confirming "your request for a dental benefit limit exception of 4/8/19 for scaling and root planning -lower left, lower right, upper left and upper right is approved as of 4/8/19 until 6/7/19 as long as you continue to have active gateway health dental coverage." At the time of the inspection on 7/16/19, the individual never received any follow up dental work, the cleaning and scaling under anesthesia, as recommended since 8/28/17. The individual also did not have a follow up appointment in February 2018 as recommended.
· Individual #1's 3/26/19 dental appointment record also states, "dispensed 2 min timer to brush with." His 8/28/17 dental appointment stated to "brush 2 times per day. se flossers in PM. rinse with act or act-like mouth rinse." There is no documentation that the timer is being used, flossing in the evening is being completed, or rinsing with ACT or ACT-like mouth wash being used during daily oral hygiene care.
· Individual #1's dentist indicated on his 8/28/17 dental appointment record, that he is to return for 6-month cleaning recalls. At the time of the 7/16/19 inspection, the individual did not have another return dental cleaning appointment until 3/5/19, one year and 7 months later. There was no documentation of the individual's refusal to attend scheduled appointments or a reason for the late appointment.
(continued on next page) | 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.
| All medical appointments are being scheduled for the month of August. Any follow up treatments and recommendations will be implemented upon return from the visit.
Staff will be retrained on the importance of follow up of medical care for the clients. Medical appointments will be monitored by the coordinator monthly and the Manager and Director Quarterly. |
09/01/2019
| Not Accepted |
| 6400.144 | page 3 continued
· On 2/9/17, Individual #1's Optometrist recommended annual eye exams. The individual was not seen again for an annual optometrist exam until 10/9/18, one year and 6 months later.
· Staff #1 stated in Individual #2's record, that the individual was not able to attend his scheduled physical examination on 6/19/19 due to staff error and no fault of the individual himself. The agency is responsible for ensuring the individual attends appointments that are arranged, and staff error is inexcusable.
· Individual #2's 5/3/18 dental hygiene plan from Erica M.Toth DMD with Welsh Mountain Dental Associates recommends "Daily cleaning of oral tissue with warm cloth and Listerine rinses". The individual's 4/30/19 dental hygiene plan from Welsh Mountain Dental Associates recommends "Rinse mouth twice daily with saline solution or Listerine, and clean gums daily with a warm washcloth." There is no documentation that the dental hygiene plan is being implemented or documentation of the individual's refusals.
Staff #12 initialed as administering Lizness 145mcg to Individual #1 at 4pm on 2/1/19. The medication was also crossed off with a line through it and "discontinued 12/31/18 (Staff #1 or #10)" written next to the medication. There was no documentation from Staff #1, #10 or #12 indicating if the medication was administered or omitted. The provider was unable to determine whether Staff #1 or #10 made the entry "discontinue 12/31/18" due to both staff having the same initials. | 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.
| All medical appointments are being scheduled for the month of August. Any follow up treatments and recommendations will be implemented upon return from the visit.
Staff will be retrained on the importance of follow up of medical care for the clients. Medical appointments will be monitored by the coordinator monthly and the Manager and Director Quarterly. |
09/01/2019
| Not Accepted |
| 6400.145(1) | Over the course of the 3-day, unannounced inspection, a written emergency medical plan that included the (1) hospital or source of health care that will be used in an emergency, (2) the method of transportation to be used, and (3) an emergency staffing plan could not be located at the home for Individual #1 or in their record. *there was an emergency medical plan in Individual #2's record that was specific to individual #2's hospital and needs. An emergency medical plan for staff to follow for Individual #1 and their hospital preference was not in the home. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | Prior to the 3 day inspection, the previous Manager was in the process of updating the client charts and updated Individual #2¿s record and did not get to update Individual #1¿s record. This was updated and placed on the chart. This record will be maintained going forward by the IDD Coordinator or their designee going forward. Routine chart audits will be performed by the Coordinator, Manager and the Compliance department to ensure that these and all documents are current on the charts. |
08/30/2019
| Not Accepted |
| 6400.151(c)(2) | Staff #4's 8/6/18 physical examination form did not include information or her last recorded Tuberculin skin test or chest x-ray and the results. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | There was a chest xray on file attached to staff #4's physical that noted that her chest was clear and she was free from any communicable disease dated Aug 2016 |
08/05/2019
| Not Accepted |
| 6400.151(c)(3) | Staff #4's 8/6/18 physical examination form did not include a signed statement that she is free of communicable diseases. This was left blank on the physical examination form. Staff #4 has been working with the individuals since 8/6/18. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Upon further review it was noted that the physician did omit checking this box on the physical form. The Physician was contacted and did complete that section of the physical. |
08/05/2019
| Not Accepted |
| 6400.165 | Individuals #1's and #2's medication administration records (mars) contained many blanks on every month's mar, without an explanation if the medication was administered or omitted. During the 7/16/19 onsite inspection, staff could not confirm that the individual's medications were administered for any blank witnessed on the individuals' mars. Documentation of the medication errors and follow-up action taken was not completed or kept in the record.
Some examples of blanks, and medications not administered, found on Individual #1's mars were:
· 8PM dose of Amantadine 100mg on 7/16/19
· 8PM dose of Oxcarbazepine 600mg for seizures on 7/15/19
· 8PM dose of Clotrimazole on /7/11/19 and 7/12/19 and blank for 8AM dose on 7/14/19
· 8AM dose of Clotrimazole on 6/23/19
· All 8AM doses of medications on 5/31/19: Amantadine, Aspirin, Chlorpromazine, Fiber lax, Lactulose, Levothyroxine, Oxcarbazepine, Polyeth glycol, Propranolol, and vitamin d3
· 8PM dose of Clozapine 5/27/19 and 5/28/19
· 8PM dose of Amantadine on 3/31/19
· 8PM dose of Clozapine 100mg on 3/4/19 and 3/6/19
· 8PM doses of Trazadone 100mg, Lithium Carbonate 600mg, Oxcarbazepine 600mg, Propranolol 40mg, Simvastatin 20mg, Amantadine 100mg, Clozapine 100mg, and Fiber lax on 3/1/19
The following medications were not initialed as administered to Individual #2:
· 8AM doses of Citalopram 40 mg, Bumetanide .5mg, Levothyroxine 75mcg, Potassium CHL 20 MEQ, Thera M, Docusate 100mg, Allopurinol 100mg, Gabapentin 100 mg, and Risperdone 2mg on 5/31/19
· 4PM dose of Alfuzosin ER 10mg on 5/31/19, 3/22/19, 2/28/19, and 2/17/19
· 12 PM dose of Maxitrol 3.5 mg/Ml ON 5/7/19
· 8AM doses of Docusate 100 mg, Allopurinol 100 mg, on 4/30/19
· 8PM dose of Aspirin CHS 81 mg, Cetaphil cream, and Divaloprex 2000 mg on 4/30/19
· 4PM dose of Maxitrol 3.5mg/ml on 3/7/19
· 12PM dose of Maxitrol 3.5mg/ml on 3/3/19
· 8PM dose of Gabapentin 100mg, Myrbetriq ER 50mg on 3/1/19
· 4PM doses of Risperdone 2mg and Maxitrol 3.5mg/ml on 3/1/19
· 8PM dose of Aspirin CHS 81mg, Cetaphil cream, Divaloprex 2000mg, Gabapenin 100mg, Myrbetriq ER 50mg, Olanzapine 15mg, Oxybutynin 5 mg, Risperdone 2mg, Zolpidem 5 mg and Maxitrol 3.5 mg/mL on 2/28/19
· 4PM dose of Risperdone 2mg and Maxitrol 3.5 mg/mL on 2/28/19
· 8PM dose of Gabapentin 100mg, Myrbetriq ER 50mg, Olanzapine 15mg, Oxybutynin 5 mg, Risperdone 2mg, Zolpidem 5 mg on 2/27/19
· 4PM dose of Risperdone 2mg on 2/27/19
· 12PM dose of Maxitrol 3.5mg/ml on 2/27/19 and 2/26/19
· 8PM dose of Risperdone 2mg on 2/23/19
· 8PM dose of Divaloprex 2000mg on 2/17/19
page 1, continued on next page | Documentation of medication errors and follow-up action taken shall be kept.
| An audit of all the current medication logs will be completed by 8/12/19. Any medication errors noted will be properly addressed including entering into EIM. During this unannounced visit it was discovered that there were staff that were not current in their medication administration training. There is a medication class scheduled for Aug 14 & 15 to get staff trained. Additionally, we will be getting other management staff trained to become a trainer in the upcoming months. This will ensure that routine med classes will occur and there will be more trainers available to do practicums throughout the year. |
09/30/2019
| Not Accepted |
| 6400.165 | page 2, continued
The following information is more examples of medications not being administered per doctor's orders, and documentation of the medication error and follow up action taken was never reported or completed.
Staff #3 or #10 initialed as administering Individual #1's Clotrimazole at 8PM on 5/8/19 then crossed it off. There is no explanation if this medication was administered or omitted. Staff #3 and #10 have the same initials and the agency could not determine who made this documentation in the individual's record. According to the Department's medication administration course, if two staff have the same initials, one staff is to use their middle initial for an identifier. Two staff should not have used the same initials when documenting administering medications to an individual.
Individual #1's current July 2019 physician's orders in his record from Dr. Sullivan, state that the individual is prescribed Linzess cap 145 mcg take daily. According to the individual's medication administration record (mar), this medication hasn't been administered since 12/4/18. There was a 30-day supply of Linzess 145mcg capsules at the home dispensed from the pharmacy on 6/2/19. None of the pills were popped out of their packaging or administered per the doctor's order.
There is no documentation of Individual #1's Clotrimazole being applied twice a day, as ordered, until 6/6/19.
Individual #1's podiatrist stated on 6/5/19 "foot fungus on both feet. meds prescribed by doctor and fax by doctors office to Elwyn Pharmacy." According to Individual's June 2019 medication administration record, a new medication was never administered after their 6/5/19 podiatrist appointment.
Individual #1's ISP states that "(he) could become a danger to himself or others if he did not have the daily support to maintain structure and medication compliance." During the 7/16/19 inspection, the individual's November 2018 medication administration records for the month were missing and could not be located. It was unknown from any agency staff if Individual #1 ever received his medications for the entire month of November 2018. | Documentation of medication errors and follow-up action taken shall be kept.
| An audit of all the current medication logs will be completed by 8/12/19. Any medication errors noted will be properly addressed including entering into EIM. During this unannounced visit it was discovered that there were staff that were not current in their medication administration training. There is a medication class scheduled for Aug 14 & 15 to get staff trained. Additionally, we will be getting other management staff trained to become a trainer in the upcoming months. This will ensure that routine med classes will occur and there will be more trainers available to do practicums throughout the year. |
09/30/2019
| Not Accepted |
| 6400.173 | During the onsite inspection on 7/16/19, Individuals #2 and #3 were witnessed partaking in lunch provided by Staff #9. The only food item offered to the individuals for lunch was one ham and cheese sandwich and a juice box container for each individual. Individual #2 indicated that he was still hungry and licensing staff had to instruct Staff #9 to make the individual another sandwich as he requested. | The quantity of food served for each individual shall meet minimum daily requirements as recommended by the United States Department of Agriculture, unless otherwise recommended in writing by a licensed physician.
| Individuals in the home currently make recommendations for meals and a well-balanced meal is provided according to each individual's prescribed diets. Staff are currently working with clients on meal planning and portions to ensure that they are able to eat additional healthy choices. |
08/01/2019
| Not Accepted |
| 6400.211(b)(1) | Individual #1's record does not include the name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. His record indicated a former Holcomb Staff #10 was the individuals designated person to be contacted in case of an emergency. At the time of the inspection on 7/16/19, this is staff is not an applicable emergency contact.
Individual #2's record does not include the name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. His record indicated a former Holcomb Staff #8 was the individuals designated person to be contacted in case of an emergency. At the time of the inspection on 7/16/19, this is staff is not an applicable emergency contact. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| The Emergency medical contact information for Individual #1 will be updated. This includes the name, address and telephone number of the person able to give consent for medical treatment. The Coordinator will review all records monthly to be certain that this information is in the record |
08/16/2019
| Not Accepted |
| 6400.211(b)(3) | Individual #1's record does include the name, address and telephone number of the person able to give consent for emergency medical treatment. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| The Emergency medical contact information for Individual #1 will be updated. This includes the name, address and telephone number of the person able to give consent for medical treatment. The Coordinator will review all records monthly to be certain that this information is in the record |
08/16/2019
| Not Accepted |
| 6400.216(a) | REPEAT from 1/31/19 annual inspection: All individual's records were found unlocked and accessible from the time we arrived at 9am on 7/16/19 until the last day of the inspection on 7/18/19. Staff #3 confirmed on 7/16/19 that individuals' record information is left unlocked all the time.
Individuals' records were found unlocked and accessible downstairs who do not reside at this home. Record content found unlocked and accessible throughout the entire home included individuals' Individual Support Plans, behavior support information, medication administration records, supervision information, incident reports, physicals, doctor's orders, medical appointments, emergency information, medical histories, assessments, financial records, etc. Some of the individual's medical information was posted in the hallway and in the staff area of the home for all visitors to see. | An individual's records shall be kept locked when unattended.
| All records are locked. Staff #3 is currently suspended. All staff have been re-trained by IDD Director to maintain records in locked cabinet in a locked room. To monitor compliance with this regulation any administrator who comes to the home checks that the records are maintained locked. Additionally, the coordinator will complete monthly EOC audits and monitor that records are locked |
08/01/2019
| Not Accepted |
| 6400.18(a)(12) | As referenced in 6400.22(c), a purchase order (k132761510) from Peapod (Giant foods) indicates that a delivery of grocery items to 3112 Cochran Drive occurred on 07/15/19 which included four, Arm and Hammer, 2 in 1 Laundry detergent power packs, clean burst scent. Each package of Arm and Hammer detergent contained 21 individual packets of laundry detergent pods, for a total of 84 laundry pods being delivered. One pod is to be used during each load of laundry.
During a morning site inspection on 07/18/19 at 5740 Main Street, East Petersburg, Staff #9 from Cochran Drive contacted house supervisor, Staff #3, who was at the Main Street residence, to request laundry detergent as there was "none at the Cochran drive residence." Three days prior to this phone call, 84 laundry pods were delivered to Cochran Drive. Upon site inspection back at Cochran drive, there was no laundry detergent found by a licensing representative. The individual's pay room and board to the agency monthly that is to cover items such as laundry detergent to be shared at the home. Room and board money was used to purchase 84 laundry pods 3 days prior to the unannounced inspection. 84 loads of laundry were not completed in 3 total days at the home. Therefore, the individual's funds used to purchase the laundry pods, were not used solely for the individuals' benefit as the pods are missing from the home.
The agency was instructed on 7/18/19 to enter an incident of misuse of funds into the Electronic Incident Management (EIM) reporting system and complete an investigation of the incident. As of 7/29/19, the incident has not been entered into EIM for Individuals #1-#3. This does not comply with the department's requirement of reporting misuse of individual's funds within 24 hours of discovery.
The regulatory requirements have not changed however, the regulatory number associated with it has. This requirement was previously recorded under 6400.18(c) but is now captured under 6400.18(a)(12). | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Theft or misuse of individual funds. | This incident will be reported in EIM and investigated. |
08/06/2019
| Not Accepted |
| 6400.34(a) | Individual #1 had their rights reviewed with them on 8/10/17 and 8/10/18. However, documentation of the review of his rights did not include of review of his rights as described under 6400.33(a), (e), (g), (j), (l), and (m). Those rights not reviewed with him were: an individual may not be neglected, abused, mistreated or subject to corporal punishment, an individual has the right to privacy in bedrooms, bathrooms and during personal care, an individual has the right to receive scheduled and unscheduled visitors, communicate, associate and meet privately with family and persons on the individual's own choice, an individual who is of voting age shall be informed of the right to vote and shall be assisted to register and vote in elections, an individual has the right to be free from excessive medication, and an individual may not be required to work at the home, except for the upkeep of the individual's personal living areas and the upkeep of common living areas and grounds.
Individual had his rights reviewed with him again on 5/6/19. However, documentation of that review of his rights, did not include a review of the individual's rights described until 6400.33(a), (b), (c), (f), (g), (h), (i), (j), (k), (l) and (m). In addition to the rights described above, this includes: an individual may not be required to participate in research projects, an individual has the right to manage personal financial affairs, an individual has the right to receive, purchase, have and use personal property, an individual has the right to unrestricted mailing privileges, and an individual has the right to practice the religion or faith of the individual's choice.
The requirement of reviewing the individual's 6400.33 rights with them, was previously addressed until 6400.31(a). The terminology and requirement for this regulation have not changed, just the number associated with the regulation has. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Our Client Rights form is being revised to ensure that all rights are reviewed annually per the regulations. |
08/30/2019
| Not Accepted |
| 6400.52(a)(1) | Staff #4 and #3 only received 10.5 hours and 6 hours, respectively, of training related to human services in the last training year from June 1, 2018 until May 31, 2019.
The regulatory requirement of direct service workers completing 24 hours of training related to job skills and knowledge each year has not changed. The regulator number associated with this requirement until 6400 is now 6400.52(a)(1) instead of previous 6400.46(a). | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Staff #4 and Staff #3 are scheduled to complete 24 hours of annual required trainings.
Additionally, all staff files were reviewed and will be monitored monthly by the Program Coordinator and Quarterly by the Program Manager. IDD Director will review that all staff have required trainings. If a staff member or consultant or contractor do not have required trainings they will complete immediately. |
09/30/2019
| Not Accepted |
| 6400.163(a) | The medication label for Individual #1's Clotrimazole and Betamethasone Dipropionate cream was illegible. The pharmacy label was so worn off that you could not make out the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician.
The regulatory requirement for this regulation has not changed. However, the regulatory number associated with the requirement has. This regulation was previously listed as 6400.162(a). | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | The medication Clotrimazole and Betamethasone Dipropironate cream is being kept in the original labeled container. As indicated by the auditors the pharmacy label has worn out. IDD Program Manager requested that the Pharmacy send out new labels for the medication so that the label could be easily read. |
08/12/2019
| Not Accepted |
| 6400.163(d) | - On 7/16/19, upon arrival to the home, all Individuals' medications were unlocked and accessible to anyone in the home. The medications were stored in the hallway closet. Individuals #2 and #3 were home. On 7/17/19, Individual #2 and #3 were present at the home, and all medications were unlocked and accessible in the same hallway closet. Individual #1 is diagnosed with Schizoaffective D/O, Bipolar D/O, a history of poor impulse control that resulted in psychiatric hospitalization, and current, occasional suicidal threats. The agency documents in Individual #1's record, he is currently exhibiting symptoms of his psychiatric disorders. Per agency Staff #5 and Staff #13-#16, they are unaware if Individual #1 was ever assessed to be safe around poisonous materials during episodes of suicidal threats, poor impulse control, or symptoms of their psychiatric diagnoses that could inhibit the individual's ability to understand how to use or avoid poisonous materials. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | It is Holcomb¿s policy that all medications be locked and secure at all times when not being administered. On 7/17/19 the third shift staff person had administered medication prior to leaving shift and had forgot to lock the medication closet; it was reviewed with this and all staff persons in the home on proper medication storage. Since that time, a sign was placed on the medication closet by the Director of IDD Services as a reminder that the closet must stay locked at all times. All individual's ability to safely avoid poisonous materials was reviewed and updated appropriately as necessary. This info was reviewed with current staff and will be reviewed with any new coming staff during their site orientation. |
08/30/2019
| Not Accepted |
| 6400.165(c) | As referenced in 6400.166(a)(12) and (13) and 6400.165, Individuals #1's and #2's medications were consistently not administered according to the directions specified by their licensed physician on numerous occasions. Some of the medications not administered according to their directions, were prescribed for Bipolar d/o, Parkinsons, Schizoaffective disorder, Seizure d/o, and other mental health disorders. There was no documentation that the agency contacted the individual's physicians to notify them of the missed medication and follow-up action to be taken.
The regulatory requirements of this regulation have not changed, however the regulatory number associated with it has. This regulation was previously captured under 6400.167(b) and is now captured under 6400.165(c). | A prescription medication shall be administered as prescribed. | During this unannounced visit it was discovered that there were staff that were not current in their medication administration training. There is a medication class scheduled for Aug 14 & 15 to get staff trained. Additionally, we will be getting other management staff trained to become a trainer in the upcoming months. This will ensure that routine med classes will occur and there will be more trainers available to do practicums throughout the year. |
09/30/2019
| Not Accepted |
| 6400.165(g) | REPEAT from 1/31/19 annual inspection: Individual #1 is prescribed medication to treat symptoms of a diagnosed psychiatric illness. A review with documentation by a licensed physician at least every 3 months that included the reason for prescribing the medication, the need to continue the medication and the necessary dosage was not completed for the individual. He was seen by his physician on 5/14/19, 1/25/19 and 7/26/18. The reviews completed on 1/25/19 and 7/26/18 do not include the reason for prescribing each psychotropic medication.
· Individual #2 had a review with documentation by a licensed physician on 09/21/18 and not again until 05/09/19, outside the at least every 3 month regulatory requirement.
The language in this regulation has not changed however the regulatory number associated with it has. The current requirement is listed until 6400.165(g) and the previous requirement was captured under 6400.163(c). | 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. | While previous reviews (those prior to 1/31/19) did not include the reason for prescribing the medication the most reason review did include this information. At each psychiatric appointment the psychiatrist completes documentation to indicate the reason for prescribing the medication. The program Coordinator will review the documentation following every medication appointment to be certain that the documentation captures all necessary information.
Follow up Psych appointments will be scheduled for both client#1 & client #2 for a medication review. |
08/30/2019
| Not Accepted |
| 6400.166(a)(12) | Staff #12, who did not indicate their name to determine their identity, initialed Individual #1's mediation administration record (mar) on 3/27/19 and 3/28/19 for administering Acetaminophen 500mg. However, Staff #12 did not include the time of administration.
The March 2019 mar for the individual also had "7:39" recorded for administration of Acetaminophen 500mg on 3/1/19. This record does not include the time of day with AM or PM or indicate the staff who administered the medication.
· Staff #4 initialed that she administered all of Individual #1's 8pm medications to him on 4/31/19. However, there isn't 31 days in April.
Individual #1's Individual Support Plan (ISP) states that "(he) could become a danger to himself or others if he did not have the daily support to maintain structure and medication compliance." During the 7/16/19 inspection, the individual's November 2018 medication administration records for the month were missing and could not be located. It was unknown from any agency staff if Individual #1 ever received his medications for the entire month of November 2018.
The language in this regulation has not changed however the regulatory number associated with it has. The current requirement is listed until 6400.166(a)(12) and the previous requirement was captured under 6400.164(a). | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | An audit of all the current medication logs will be completed by 8/12/19. Any medication errors noted will be properly addressed including entering into EIM. During this unannounced visit it was discovered that there were staff that were not current in their medication administration training. There is a medication class scheduled for Aug 14 & 15 to get staff trained. Additionally, we will be getting other management staff trained to become a trainer in the upcoming months. This will ensure that routine med classes will occur and there will be more trainers available to do practicums throughout the year. |
08/12/2019
| Not Accepted |
| 6400.166(a)(13) | There are multiple medication administration records (mars) for Individual #1 where the staff's name who administered the individual's medication were not legible. There were also multiple mars in which the staff who administered medication to the individual did not sign the mar to indicate who administered the medications. Some examples of staff initialing Individual #1's mar for administering medications but not signing to mar to indicate who the staff was, included: Staff #10 administered medications in July 2019, Staff #12 administered medications in June 2019 and March 2019, Staff #4 and Staff #3 or #10 administered medications in May 2019, and Staff #4 administered medications in April 2019 without indicating on the mar the name of the staff administering the medications.
Staff #12 initialed as administering Lizness 145mcg to Individual #1 at 4pm on 2/1/19. The medication was also crossed off with a line through it and "discontinued 12/31/18 (Staff #1 or #10)" written next to the medication. There was no documentation from Staff #1, #10 or #12 indicating if the medication was administered or omitted. The provider was unable to determine whether Staff #1 or #10 made the entry "discontinue 12/31/18" due to both staff having the same initials.
Staff #12, who did not indicate their name to determine their identity, initialed Individual #1's mar on 3/27/19 and 3/28/19 for administering Acetaminophen 500mg. However, Staff #12 did not include the time of administration.
The March 2019 mar for the individual also listed "7:39" recorded for administration of Acetaminophen 500mg on 3/1/19. This record does not include the time of day with AM or PM or indicate the staff who administered the medication.
There were multiple times where the staff initialing as administering medication to Individual #1 had the same initials as each other. The agency was unable to provide documentation to determine which staff administered medications.
The language in this regulation has not changed however the regulatory number associated with it has. The current requirement is listed until 6400.166(a)(13) and the previous requirement was captured under 6400.164(a). | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | During this unannounced visit it was discovered that there were staff that were not current in their medication administration training. There is a medication class scheduled for Aug 14 & 15 to get staff trained. Additionally, we will be getting other management staff trained to become a trainer in the upcoming months. This will ensure that routine med classes will occur and there will be more trainers available to do practicums throughout the year. |
09/30/2019
| Not Accepted |
| 6400.169(a) | Staff #4 has been administering medications to Individuals #1-#3 for the last year. There is no documentation that she received or passed the Department's Medication Administration Course initially or annually.
Staff #3 confirmed on 7/16/19 that she was the main staff that was administering mediations to Individuals #1-#3. There is documentation that she received and passed the Department's Medication Administration Training course on 3/15/18 but not again since then. This is outside the annual time frame requirement. Thus, she is not certified to administer medications to any individual after 3/15/19. She documented as administering medications to the individuals for the entire 2019 year.
Staff #11 initialed as the medication trainer for Staff #3's 3/15/18 medication administration training. There is no documentation that Staff #11 was a medication trainer, certified by the Department's Medication training Train the Trainer Course.
Staff #3's and 4's medication training documents and Staff #11's medication trainer certificate were requested multiple times during the onsite inspection from 7/16/19-7/18/19 and for the week following the inspection. Nothing was provided.
Regulatory requirements for this regulation have not changed, however the number associated with the regulation has. The regulatory requirements were previously recorded under 6400.168(a) and (d). Now they are recorded until 169(a). | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | During this unannounced visit it was discovered that there were staff that were not current in their medication administration training. There is a medication class scheduled for Aug 14 & 15 to get staff trained. Additionally, we will be getting other management staff trained to become a trainer in the upcoming months. This will ensure that routine med classes will occur and there will be more trainers available to do practicums throughout the year. |
09/30/2019
| Not Accepted |
| 6400.188(a) | - Individual #2 requires assistance with financial management. Holcomb serves as the representative payee. Individual #2's record contained an email from previous Holcomb CEO, Staff #6, to Staff #7 on April 29, 2019 that read, "Social Security stopped the individual's payment due to Rep Payee forms not being received timely per a phone call made by [Staff #8] and [Staff #6] in January. We contacted our fiscal dept about this - the Rep Payee form was completed and forwarded to SS by Chimes, Holcomb's parent company. [Staff #8] and [Staff #6] were advised, per the SS representative we spoke with in January, to follow up with the local office in Lancaster to rectify this. When [Staff #6] spoke to [Staff #8] about this recently she had not yet gone to the local office."
Holcomb failed to aid with the acquisition and maintenance of Individual #2's financial resources. Individual #2's social security funds were not provided to him from January 2019 until April 2019 because Holcomb failed to follow through with the steps listed above. As of 7/16/19, Holcomb staff were unable to determine if the individual's funds had been reinstated.
As noted in 6400.16, Holcomb failed to ensure medication trained staff members were working on each shift in the home. It was almost a daily occurrence that the only staff member working in the home during times of medication administration were staff who were not certified to administer medications. Because of this, Individuals residing in the home were not able to receive prescribed medications. Staff #3 reported to licensing staff on 7/16/19 that she is the home supervisor and works primarily at another residential home but is required, most days, to go to the Cochran drive home to administer medications. The individuals have not been given assistance and support for consistent medication administration. | The home shall provide services, including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment. | During this time, Holcomb BHs was transitioned to Chimes International (Parent Company). During this transition there was a lag in filing the paperwork for redetermination for Individual #2 Social Security Funds. According to his financial statement funds were reinstated in May 2019 and he received a large payment of $6014.00 which posted on May 1, 2019. Since this time a designated person in Chimes handles all redetermination paperwork to be filed with Social Security. The papers are received in Holcomb's main office in Exton and then scanned and emailed to a designated person in Chimes and the paperwork is completed and submitted. Since this incident, there have been no further incidents of delayed paperwork filing or clients losing funding
During this time this home had lost a Supervisor and the IDD Coordinator who were both med trained leaving limited staff to give out and monitor medication. Med trained staff have been available to administer medications per the physician¿s orders.
Moving forward, all IDD Coordinators and the Manager will be med trained and maintain a Train the Trainer certificate. This will ensure that not only do we have enough staff trained in medication administration, we will have managers that can conduct the class regularly, complete practicums timely and assist with medication monitoring. |
08/30/2019
| Not Accepted |
| 6400.188(b) | The agency has not provided consistent or regular opportunities for any individuals in the home to participate in community life. There is no documentation by community outing logs to indicate what community participation outings have been offered to the individuals in the home.
Individual #2 reported during the 7/16/19 inspection that he stays at his home every day and only goes into the community with a habilitation worker who is not employed by the residential Holcomb agency. Direct support Staff #3 confirmed that the individuals are not offered participation in community life outside of a service that is being provided by a different agency. Staff #9 stated that they can not get individuals into the community because there is not enough staff in the home for the 3 individual's needs out in the community.
During the onsite inspection on 7/16/19, Individual's #2 and #3 fell asleep sitting in chairs in the staff office area due to no in-home programming or community participation being provided. The individuals were witnessed to be sitting in the chairs for a few hours before falling asleep. | The home shall provide opportunities and support to the individual for participation in community life, including volunteer or civic-minded opportunities and membership in National or local organizations. | All staff will be trained on the the importance of community life and activities. Staff will encourage individuals to identify activities of interest and schedule events based on these activities. IDD Coordinator and Program Manager will review community schedules monthly. |
08/12/2019
| Not Accepted |
| 6400.213(1)(i) | The face sheet contained in Individual #2's red, three-ring emergency binder that is to be taken with him in the event of an emergency or provided to law enforcement should he go missing, does not include his weight, height, race, hair color, eye color or identifying marks.
This regulatory requirement is found under 6400.213(1)(ii). However, this specific number is missing from the electronic system. The regulation is still a requirement and written as: "Each individual's record must include the following information: The race, height, weight, color of hair, color of eyes and identifying marks." | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The face sheet for Individual #2 will be updated to include weight, height, race, hair color, eye color or other identifying marks. Coordinator will review all files monthly to be certain face sheet is completed and accurate. IDD Director or Program Manager will review files quarterly to be certain all documentation is completed. |
08/12/2019
| Not Accepted |
| 6400.213(1)(i) | Individuals #1's and #2's records do not indicate their primary language or means of communication spoken or understood.
This regulatory requirement is found under 6400.213(1)(iii). However, this specific number is missing from the electronic system. The regulation is still a requirement and written as: "Each individual's record must include the following information: 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." | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Records for Individual #1 and Individual #2 were reviewed and will be updated to include primary language or means or communication. Face sheet for Individual #2 was reviewed and will be updated. This includes his weight, height, race, hair color, eye color and identifying marks. Coordinator will review all files monthly to be certain face sheet is completed and accurate. IDD Director or Program Manager will review files quarterly to be certain all documentation is completed. |
08/12/2019
| Not Accepted |
| 6400.213(7) | Individual #1's Individual Support Plan (ISP) in his record was last updated on 12/28/18. According to the electronic system where individuals' ISPs are visible, the individual has had 3 critical revisions and a fiscal year renewal completed since 12/28/18. His most current ISP, updated on 6/24/19, is not kept in his record or at the home. Staff working in the home do not have access to the electronic system to view the individual's most current ISP.
The regulatory requirement to keep all current information in the individual's record at the home has not changed. However, the regulatory number associated with the requirement has changed. This requirement was previously located under 6400.213(9) and is not captured under 6400.213(7). | Each individual's record must include the following information: Individual plan documents as required by this chapter. | New ISP for Individual #1 was been printed and placed on the chart. New ISP was reviewed with all staff and staff signed the acknowledgement sheets. Coordinator will review all files monthly to be certain updated ISP is in the record. IDD Director or Program Manager will review files quarterly to be certain all records contain updated ISP. |
08/12/2019
| Not Accepted |