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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | VCS's Covid-19 Coronavirus Policy and Monitoring Response Plan states, "Staff is to notify health care providers of all individuals in the home of possible exposure due to a positive result of a housemate and request testing for Covid-19." Individual #1's health care provider was not notified of the possible exposure until 9/7/21, 4 days after symptoms commenced. Staff #2 instructed staff to get Individual #1 tested on 9/3/21 but did not follow up to ensure testing was completed as per the policy. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | As a response to the death investigation, VCS reviewed current policy and ensured compliance with CDC and DOH guidelines. Covid-19 Coronavirus Policy and Monitoring Response Plan was retrained with all program managers, program specialists, and operation directors on 09/20/21. See Attachment #1 The policy had a guideline/checklist added as a quick guide for ease of use. See Attachment #2. This was implemented and distributed to the program managers, program specialists and operations directors by the Pandemic Response team on 11/24/21. |
11/24/2021
| Implemented |
| 6400.144 | · On 9/3/21, Individual #1's housemate (Individual #2) tested positive for Covid-19. Staff #2 instructed Staff #1 at Individual #1's home to get Individual #1 tested immediately. Individual #1 was not tested for Covid-19 until 9/8/21.
· VCS's Covid-19 Coronavirus Policy and Monitoring Response Plan states, "Staff is to notify health care providers of all individuals in the home of possible exposure due to a positive result of a housemate and request testing for Covid-19." Individual #1's health care provider was not notified of the possible exposure until 9/7/21, 4 days after symptoms commenced. Staff #2 instructed staff to get Individual #1 tested on 9/3/21 but did not follow up to ensure testing was completed as per the policy. | 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.
| Following ODP guidelines regarding Incident Management, during the death investigation a neglect investigation was started on 09/14/2021. Response to the confirmed investigation is outlined. As a response to the death investigation, VCS reviewed current policy and ensured compliance with CDC and DOH guidelines. Covid-19 Coronavirus Policy and Monitoring Response Plan was retrained with all program managers, program specialists, and operation directors on 09/20/21. See Attachment #1 See Attachment #1 The policy had a guideline/checklist added as a quick guide for ease of use. See Attachment #2. This was implemented and distributed to the program managers, program specialists and operations directors by the Pandemic Response team on 11/24/21. A requirement was also put in place on 11/24/21 necessitating a refresher training by the operations director on a quarterly basis. See Attachment #3 This is due by the end of February 2022.
To ensure no further infractions occur, a procedure was trained to the program managers, program specialists, and operations directors on both 02/09/22 and 02/10/22 by the Director of Quality Assurance and Training. See Attachment #4 The procedure requires the Operations Director to email and text both the program manager and program specialist of the need to have individuals living in the home to be scheduled for testing immediately. This does not preclude the Covid-19 Coronavirus Policy and Monitoring Response Plan requirement to contact the individuals¿ physician, but as another measure to ensure testing. |
02/10/2022
| Implemented |
| 6400.32(c) | Individual #1 was diagnosis with Atherosclerotic Heart Disease of Native Coronary Artery without Angina and receiving hospice care as of 6/7/21. Valley Community Services (VCS) failed to seek medical care for individual #1 as described below:
· On 9/3/21, Individual #1's housemate (Individual #2) tested positive for Covid-19. Staff #2 instructed Staff #1 at Individual #1's home to get Individual #1 tested immediately. Individual #1 was not tested for Covid-19 until 9/8/21.
· VCS's Covid-19 Coronavirus Policy and Monitoring Response Plan states, "Staff is to notify health care providers of all individuals in the home of possible exposure due to a positive result of a housemate and request testing for Covid-19." Individual #1's health care provider was not notified of the possible exposure until 9/7/21, 4 days after symptoms commenced. Staff #2 instructed Staff #1 to get Individual #1 tested on 9/3/21 but did not follow up to ensure testing was completed as per the policy.
· Per Individual #1's record, Individual #1 displayed signs of a fever on 9/3/21, 9/4/21, 9/5/21, 9/6/21, 9/7/21 and 9/8/21. A Covid-19 test was not completed until 9/8/21.
· Individual #1 was taken to the ER via ambulance on 9/9/21 due to an oxygen level of 70% where he passed away on 9/10/21 due to Covid-19 Pneumonia.
Failure to seek medical care for individual #1 after potential exposure to Covid-19 and displaying symptoms of a fever constitutes mistreatment. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Following ODP guidelines regarding Incident Management, during the death investigation a neglect investigation was started on 09/14/2021. Response to the confirmed investigation is outlined.
As a response to the death investigation, VCS reviewed current policy and ensured compliance with CDC and DOH guidelines. Covid-19 Coronavirus Policy and Monitoring Response Plan was retrained with all program managers, program specialists, and operation directors on 09/20/21. See Attachment #1 See Attachment #1 The policy had a guideline/checklist added as a quick guide for ease of use. See Attachment #2. This was implemented and distributed to the program managers, program specialists and operations directors by the Pandemic Response team on 11/24/21. A requirement was also put in place on 11/24/21 necessitating a refresher training by the operations director on a quarterly basis. See Attachment #3 This is due by the end of February 2022.
To ensure no further infractions occur, a procedure was trained to the program managers, program specialists, and operations directors on both 02/09/22 and 02/10/22 by the Director of Quality Assurance and Training. See Attachment #4 The procedure requires the Operations Director to email and text both the program manager and program specialist of the need to have individuals living in the home to be scheduled for testing immediately. This does not preclude the Covid-19 Coronavirus Policy and Monitoring Response Plan requirement to contact the individual's physician, but as another measure to ensure testing. |
02/10/2022
| Implemented |
| 6400.169(a) | Staff #3- 2020 medication administration training documents indicated they completed and passed all the medication administration training requirements by 2/8/2020. However, one of the requirements (a medication administration record review) was not completed until 2/20/2020, therefor their 2020 training was late. A medication administration trainer did not review information after 2/8/2020 to determine if the missing mar was completed correctly, or if the additional remediation requirements were completed as required.
The medication administration review (mar) records provided for Staff #3- 2020 and 2021, staff #4 - 2020 and 2021, Staff #5- 2020 and 2021, and Staff #6- 2020 and 2021 medication administration trainings, were not Department issued records to be used for the completion of the certification. The mars provided stated they were the agency-created forms and did not include all information required, specific to the Department-approved medication administration training forms. Therefore, there is no record the mars were completed entirely and approved via the department-approved course for said staff in 2020 and 2021. | 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). | Staff #3 completed training requirements on 02/08/2020, however the medication administration record review was not completed until 02/20/20. The Quality Assurance Assistant reviewed the 2020 medication administration records where staff #3 was passing medications. No errors were found. See attachment #5. To ensure no further infractions occur, the Quality Assurance and Training department has adjusted the months for required review to ensure all documentation is completed prior to the medication administrator's anniversary date. See attachment #6.
On 02/10/2022, Program Managers who are either Medication Administration Trainers or Practicum Observers were trained by the Quality Assurance Associate utilizing the Department-approved Medication Administration Record Review form. See Attachment #7 All will begin to utilize the form as of February 2022. Documentation from each reviewer will be submitted to the Director of Quality Assurance and Training by 02/15/2022. To ensure no further infractions occur, Quality Assurance Associates will review the forms for accuracy and return any form utilizing the old VCS format to be resubmitted on the accurate form. |
02/15/2022
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.186(c)(2) | REPEATED VIOLATION - 7/19/16. Individual #1's 9/5/16, 12/9/16, 3/6/17, and 6/5/17 Individual Support Plan (ISP) Reviews did not include a review of the refusal of medical procedure protocol, choking protocol, or the dental hygiene plan. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | Valley Community Services (VCS) will ensure ISP reviews include a review of each section of the ISP specific to the residential home. The QA Director retrained the program specialists on the format of the ISP review on 9/18/2017. Attached (#1) are the sign in sheet, outline, and example of the format. Each program specialist completed their next ISP review and submitted to the QA department, which are attached (#2). To ensure no further infractions occur, the operations director and QA department will review a sample of ISP reviews each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program specialists on an ongoing basis. |
10/09/2017
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.74 | The wooden ramp out back of the home did not have a non skid surface. | Interior stairs and outside steps shall have a nonskid surface.
| Partially Implimented/Adequate Progress CSS 6/7/13
VCS will ensure all outside steps have a nonskid surface. The program managers will have retraining by the Quality Assurance Director on regulation 6400.67(a) by March 21, 2013. The wooden ramp out back of the home had the correct outdoor product applied prior to 03/08/2013. |
03/21/2013
| Implemented |
| 6400.181(a) | Individual #3's intial assessment did not contain areas of personal adjustment, water/swim safety skill levels. | (a) Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home.
| Partially Implimented/Adequate Progress CSS 6/7/13
VCS will ensure initial and annual assessment includes assessment of adaptive behavior and level of skills completed. VCS Summary of Assessment has been retooled to include all the required information. The program specialists retraining will be completed by the Program Services Director on regulation 181(a) by March 21, 2013. The sign in sheet, outline, and a completed revised Summary of Assessment will be sent on completion. To ensure further infractions do not incur, the Program Services Director will review Summary of Assessments for 3 months, ending 06/30/2013. |
03/21/2013
| Implemented |
| 6400.181(c) | The assessment for Individual#3 did not contain the basis of where the information was obtained. | (c) The assessment shall be based on assessment instruments, interviews, progress notes and observations.
| Partially Implemented/Adequate Progress CSS 6/7/13
VCS will ensure initial and annual assessment includes the basis of how the information was obtained. VCS Summary of Assessment has been retooled to include the required information. The program specialists retraining will be completed by the Program Services Director on regulation 181(c) by March 21, 2013. The sign in sheet, outline, and a completed revised Summary of Assessment will be sent on completion. To ensure further infractions do not incur, the Program Services Director will review Summary of Assessments for 3 months, ending 06/30/2013. |
03/21/2013
| Implemented |
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