| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual #1's financial record includes a receipt for food delivery from Two Cousins on 3/30/21. The receipt listed that the purchase was for the individual and a staff member that included: "1 large sausage parm sub, ½ order of fries, breaded chicken sandwich, 6 pierogis, and a 2-liter bottle of soda." Individual #1's assessment does not include an assessment that they understand or agree to purchasing food and items for the staff. The food was delivered to the home for consumption at home while the staff was on shift at the house, not out to eat in the community. The individual's assessment states they are only able to state the value of money up to $5. The individual's financial record shows a pattern of weekly purchasing food and items for staff without an assessment of the individual's understanding of these purchases and if they wish to make these purchases.
Another example of purchasing meals for staff out to eat without record of the individual's approval of the purchase was 4/27/21 receipt for Gus' restaurant and $40.51 was used for the purchase of meals, 5/11/21 food at Columbia Family Restaurant for $38.42.
During the 8/11/21 onsite inspection of the home, an agency staff was living in the attached basement apartment of the home. According to the individuals' room and board contracts and the staff rental agreement, Individuals #1-#3 were paying for the utilities (defined by the agency as electric, water, sewer, trash, etc,) and the staff living in the basement was also using said utilities but not paying for them. According to the staff's rental agreement, the Landlord defined as the agency, Friendship Community, was to pay for the staff's portion of utilities. However, the staff nor the agency was paying their portion of the utilities. | Individual funds and property shall be used for the individual's benefit. | Individual #1s Assessment and ISP include statements that Individual understands, desires, and agrees to purchasing staff meals while out in the community. Individual #1s assessment shall be reviewed and updated to eliminate any potential discrepancies between value of funds/money and their desire to purchase food for staff; or to reconsider the option of Individual #1s purchase of staff meals pending ISP Team discussion.
Immediate retraining was provided to Program Managers, Program Coordinators, and Program Specialists on the requirement for thorough assessments of financial understanding and comprehension of all Individuals occurred on 8/13/21. |
09/23/2021
| Implemented |
| 6400.22(d)(1) | During the 8/11/21 onsite inspection of the home, the home manager reported to the Department representative that Individual #1's finances were found to be missing money as of 8/10/21 and a certified investigation was initiated into the missing funds. The agency reported the individual had been missing $8.48 since 7/15/21.
Individual #1 had gift cards to multiple locations at the home: Dunkin (1), Walmart (1), Target (2), Starbucks (1), and Yoders (1). There are no records maintained for the amount of money available on all the cards at the time of the 8/11/21 inspection.
The agency reported the individual spent $14.75 at Walmart on 1/7/21 using a credit card, not a gift card. The individual does not possess a credit card. A staff member documented the money was used from a gift card; a picture of a Walmart gift card with "25.00" written on it was attached to the receipt. However, there are no records maintained of this gift card or the purchases made with this gift card, or credit card.
The agency reported there was another gift card for Individual #1 for the Lancaster Barnstormers with $6.52 left on the card. However, there are no records of any purchases with the card or the ending balance available on the card at the time of the 8/11/21 inspection.
The individuals at the home each had money located in a money bag and a lock box. When purchases were made, staff would only make sure the individuals' money bag was counted and kept up to date. The money stored in the individuals' lock box was only counted to ensure it was kept up to date approximately once or twice weekly. The home did not ensure that all individuals' funds were counted and kept up to date daily. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | A certified investigation was immediately initiated on 8/10/21 to determine the cause of the missing funds and confirm the amount of any missing funds. Certified Investigation and Administrative Review were completed on 9/6/21. Missing funds were reimbursed to the individual. Program Manager received retraining on the need to maintain current financial records on 8/10/21. |
09/23/2021
| Implemented |
| 6400.103 | The written evacuation plan for the home did not include individuals' responsibilities. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Associate Director of Operations developed a standardized Written Emergency Evacuation Procedure template that includes Individual and Staff responsibilities, Means of Transportation, and an Emergency Shelter location on 8/13/21. All Program Managers shall implement the standardized template within their program and update it to include all necessary and current information for the Individuals residing in that program by 10/8/21. |
09/23/2021
| Implemented |
| 6400.112(c) | The information required in 6400.112(c) was not recorded at the time of the 10/10/2020 fire drill held at the home. Staff did not document the time the drill was held, the length of evacuation, and other requirements until 10/12/2020, days after the drill was held. There are no records maintained that the information recorded for the 10/10/2020 fire drill record was accurate information. | 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 homes to complete an August 2021 fire drill, post Licensing, by August 25th and
submit form within one hour of completing drill. Associate Director of Operations updated Friendship Community policy to require completion of Fire Drill Record within one hour of completing the drill, and provide training on updated expectations to Program Managers and Program Coordinators on 8/20/21. |
09/23/2021
| Implemented |
| 6400.113(a) | Individual #1's, #2's and #3's, 4/6/2021 fire safety training record did not include documentation that they received training on their responsibilities during fire drills. | 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. | Individual #1, #2, and #3 shall receive fire safety training, including their responsibilities by 9/22/21. Associate Director of Operations shall develop a standardized Fire Safety Training template that includes 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 by 9/24/21. All Program Managers shall implement the standardized template within their program and update it to include all necessary and current information for the Individuals residing in that program by 10/21/21. |
09/23/2021
| Implemented |
| 6400.141(c)(7) | Individual #1's current, 10/13/2020 physical examination record did not include their most recent gynecological examination to include a breast examination and PAP smear nor evidence that the physician has deferred this examination and the reason for their deferment. The physical examination record indicated the examinations were not performed, specifically that the patient was "not examined." Individual #1's 10/7/2019 physical examination did not include the previous year's examination, the date of the examination or if the examinations were deferred. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual #1s record contained a signed statement from the physician recommending that Individual #1 not receive a GYN exam/PAP test. Program Managers, Program Coordinators, and Nurses received immediate retraining on 8/13/21 the need for physical examinations to include a gynecological examination including breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. |
09/23/2021
| Implemented |
| 6400.144 | The Center for Disease Control (CDC) recommends a Tetanus and/or Tetanus immunization booster every 10 years. As part of 6400.141(c)(3), individuals need to receive immunizations as required by the CDC. According to Individual #1's record they received a Tetanus immunization on 9/22/2010 and not again until 6/9/2021, outside the CDC recommendation. | 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.
| Individual #1 received the immunization on 6/9/21. Program Managers, Program Coordinators, and Nurses received immediate retraining on 8/13/21 on timely immunizations as required per regulations. Program Managers and Nurses shall complete an audit of all individuals current immunization status to ensure all other immunizations are current. If any immunizations are identified to be out of compliance, appropriate follow up with the Individuals physician will occur. This audit shall be completed by 10/31/21, and documentation of audit results shall be maintained on file. |
09/23/2021
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's current, 3/17/21 assessment did not include an evaluation of the individual's understanding of paying for staff food, entry fees, etc. Individual #1 is currently paying for staff meals, entry fees, etc. on a weekly basis when staff accompany the individual into the community. Individual #1's assessment and record do state that they are diagnoses with Dementia and Major Neurocognitive disorder due to Alzheimer's disease and has begun to display signs of decline through increased irritability, confusion, forgetfulness, and hallucinations. There is no documentation of the individuals acknowledgement that they understands paying for other's purchases to prevent financial exploitation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Program Specialist shall complete an updated review of Individuals current understanding of finances by 10/8/21. Program Specialist Team shall receive retraining by Program Specialist Lead on the requirement to ensure individual assessment of financial understanding is accurate and current throughout the plan year using the established Individual Assessment Addendum. This retraining shall occur by 10/8/21. |
09/23/2021
| Implemented |
| 6400.211(b)(1) | Individual #1's record did not include the name of the person to contact in an emergency. Their record stated to contact the agency but did not identify the name of whom to 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.
| Program Specialist shall update the Individuals emergency information sheet to include a specific contact name of the person(s) able to give consent for emergency medical treatment should Individual #1 be incapacitated and require treatment, along with verified address and telephone number by 9/13/2021. |
09/23/2021
| Implemented |
| 6400.165(b) | Individual #1 's medication administration labels on their Clindamycin lotion and Benzoyl Peroxide wash do not match the physician's order recorded in June 2021 or their current (or all) medication administration records (mars). According to a physician's print out on 6/9/2021, the individual is to have Benzoyl Peroxide wash and Clindamycin applied topically to affected area two times daily. The individual's mars for the previous year state that they are to apply both medications twice daily to both armpits, with specific instructions for the amount to be applied to the armpits and how to rinse the medication off. | A prescription order shall be kept current. | Individual #1s MAR, label, and order were immediately rectified to ensure all areas matched. Retraining on the need for all labels and MARs to match physician orders was provided immediately on 8/13/21 to Program Managers, Program Coordinators, and Nurses. Nurses, Medication Trainers, and/or Practicum Observers shall complete an audit of all medication labels and MARs to ensure they match current orders. This audit shall be completed by 10/31/21. Documentation of audit shall be kept on file. Any area identified throughout the audit as out of compliance shall be followed up by appropriate corrective action. |
09/23/2021
| Implemented |
| 6400.166(b) | There were a number of times that the time of day (AM or PM) was not recorded on Individual #1's medication administration record for the administration of Hydrocortisone and Ibuprofen in May 2021. Examples of the time of administration not being recorded at the time of administration for Hydrocortisone was: 5/18/21 only 8:09 was recorded, 5/19/21 only 6:53 was recorded, 5/20/21 only 6:30 was recorded, and staff initialed as administering the medication twice on 5/21/21 and a time of administration was only recorded for one of the administrations.
Bacitracin cream was applied to Individual #1 twice on 6/26/21 and the time of administration was not recorded; only 6:55 and 8:55 were recorded by staff. Bacitracin cream was applied on 6/27/21 and the time of administration wasn't recorded; only 6:34 was recorded.
Bacitracin cream was applied to Individual #1 on 8/7/21 but the time of administration wasn't recorded; only "7:37" was recorded by staff. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | All medication trained team members at Individual #1s home shall receive immediate retraining by the home nurse/medication trainer on the need to include AM/PM on PRN administration documentation. This retraining shall be completed by 9/27/21. All medication trained team members throughout Friendship Community shall receive retraining on this requirement by 10/8/21 by the Nursing Consultant. All MAR Reviews completed by Practicum Observers, Medication Trainers, or Nurses shall be confirmed to include all necessary AM/PM notations. Documentation of this verification shall be sent to the Associate Directors of Operations until 10/21/21 to ensure compliance, and further documentation shall be maintained on file henceforth. |
09/23/2021
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include a current, dated photograph that was taken within the previous year. The only dated photograph in their record was taken 2/12/2017 | Each individual's record must include the following information: Personal information, including: current dated photo | Individuals face sheet was immediately updated to include a current photograph on 8/13/21. Program Specialists shall conduct and audit of all individuals photographs and face sheets and update accordingly by 10/21/21. Associate Director of Operations shall provide retraining to Program Managers, Program Coordinators, and Program Specialist of requirement to update all individuals photographs annually. |
09/23/2021
| Implemented |