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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(a) | An unannounced fire drill was not held for December 2015. | An unannounced fire drill shall be held at least once a month. | It was discovered that this drill was not completed on January 5, 2016. A drill was conducted immediately knowing that it could not replace December's drill but out of good faith. Therefore two drills were recorded in January. All fire drills are to be completed and submitted by the 25th of the month to the Program Specialist and Quality Compliance Specialist. The QCS tracks the fire drill requirements and will then have at least 5 days ensure a drill is completed if not submitted on time. Group home drills are reviewed and audited for compliance monthly by the QCS. [Documentation of fire drill audits shall be kept. (AS 12/20/16)] |
12/15/2016
| Implemented |
| 6400.141(c)(14) | The physical examination dated 5/17/16 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency, this section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The PCP has seen Individual #1 and added an addendum to the physical to include medical information pertinent to diagnosis and treatment in case of emergency. This will be sent to the department to verify the immediate correction. This statement has been added to the physical form for completion. The Director of admissions will review this physical in it's entirety to ensure completion. This information was also reviewed with Program Specialists and Director of Nursing at the PS meeting on 12/14/16. The physical form completion will also be part of the chart audits completed by the Quality Compliance Specialist on a quarterly basis. Verification of the updated form and immediate correction will be submitted to the department, Monday 12/19/16. [Immediately, the aforementioned review process shall be implemented for all current and incoming individuals' physical examinations and missing information shall be obtained. Documentation of reviews and audits shall be kept.(AS 12/20/16)] |
12/19/2016
| Implemented |
| 6400.186(a) | The program specialist has not completed an ISP review for Individual #1, admission date 6/6/16. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | The ISP review covering from the date of Individual #1's admission through his ISP meeting review has been completed and will be sent to the department as part of this POC. All Program Specialists were trained on this to ensure compliance moving forward at the PS meeting on 12/14/16. The Program Specialist will complete the report and the Program Director will be responsible to verify completion. Compliance of an initial quarterly ISP review will also be included in the random chart audits completed quarterly by the Quality Compliance Specialist. Individual #1's report will be submitted to the department Monday, 12/19/16 for verification of immediate correction. [Documentation of audits shall be kept.(AS 12/20/16) |
12/19/2016
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.33(a) | On April 13, 2015, Individual #1 was heard screaming, swearing and threatening another Individual in his/her bedroom. Witnesses report hearing "an incredibly loud thud" and "a big boom." Individual #1 was seen lying face down on the floor with Direct Service Worker #1 lying on Individual #1's back. Individual #1 was bleeding from the mouth and stated, "You broke my fucking tooth." On 4/14/15, Individual #1 was diagnosed with a fractured jaw and received surgical intervention. | An individual may not be neglected, abused, mistreated or subjected to corporal punishment. | The staff member involved in the incident is no longer employed at EHCA effective May 8,2015.
The Behavior Specialist and Program Specialist provided training to all the staff on client #1's behavior programs and positive approaches to de-escalate behaviors for all individuals on April 22, 2015.All employees are trained at orientation and annually thereafter on Agency Expectations, Quality of Care ensuring dignity and respect for all clients, Implementation of the Hierarchy of Care, Positive Approaches, Individual Bill of Rights/Grievance Procedure, Prevention of Abuse Against Individuals, Incident Reporting, EHCA Policy for the Use of Restrictive Procedures, Emergency Procedures for the Use of Restraints and specific Behavioral Intervention Plans designated for the individuals. [As per conversation with COO on 7/28/15, COO will review current Incident Management Policy specifically for incident prevention and will update and revise as needed. (AS 7/28/15)] |
07/05/2015
| Implemented |
| 6400.196(b) | On April 13, 2015 at 7:38 PM, Direct Service Worker #1 held Individual #1's wrists and crossed them across Individual #1's chest for 2 minutes until Individual #1 broke free of the restraint. After a brief time, Individual #1 was witnessed being "restrained on the floor" in the computer room. Direct Service Worker #1, date of hire 11/17/14 was not trained in restrictive procedures. | A staff person responsible for developing, implementing or managing a restrictive procedure plan shall be trained in the use of the specific techniques or procedures that are used.
| The staff member who was not trained in CPI is not longer employed by EHCA effective May 8, 2015.
The Staff Development Coordinator reviewed the current CPI Training procedure. The current procedure requires employees working in facilities with individuals who have behaviors that warrant the use of restraint to receive CPI Training. The procedure will be revised so that all DPS¿s and client supervisory staff receive CPI training - effective September 1, 2015
The Staff Development Coordinator will revise the Training Policy to include this change August 3, 2015.
The Staff Development employees will review the list of employees who are currently required to have CPI training and ensure that they have completed the CPI Training. The Staff Development and Training Department will schedule CPI Training for all are required to have the training but are not currently trained by August 28, 2015.
The Staff Development employees will monitor employee CPI training: Every month, the list of employees who will expire the following month will be generated. All employees on the list will be scheduled for CPI training prior to their expiration date. The employee and their supervisor will be notified of the scheduled training through email and the Care Tracker. At the end of the month, ¿Failure to Attend Notices¿ will be sent to all supervisors, identifying employees who did not attend. The employees will be rescheduled for CPI training and moved to a house with individuals who do not have behaviors that may warrant the use of restraint until they are successfully certified. Effective July 1, 2015
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07/05/2015
| Implemented |
| 6400.205 | On April 13, 2015 at 7:38 PM, Direct Service Worker #1 held Individual #1 by the wrists and crossed Individual #1's arms across Individual #1's chest and then Direct Service Worker #1 restrained Individual #1 on the floor. Direct Service Worker #2 timed the restraint at 2 minutes in duration. The "Behavior Incident Report Form" documents the length of the restraint as 1-1 1/2 minutes. In addition, Individual #1's condition following the removal of the restrictive procedure is not documented. | A record of each use of a restrictive procedure documenting the specific behavior addressed, methods of intervention used to address the behavior, the date and time the restrictive procedure was used, the specific procedures followed, the staff person who used the restrictive procedure, the duration of the restrictive procedure, the staff person who observed the individual if exclusion was used and the individual's condition following the removal of the restrictive procedure shall be kept in the individual's record.
| The Behavior Report Form was revised to reflect the accurate time of restraint to be 2:00 minutes. The PS reminded the staff to ensure that documentation reflects accurate information.
The On ¿ Call Supervisor reported to the facility in response to the incident. She evaluated the situation, individual #1, and ensured the safety of all staff and clients.
The nurse also reported to the facility in response to the incident. She evaluated individual #1 on 4/13/15 at 9:30 following the restraint and documented her findings on the Individual Concern Report Form.
The COO will revise the Behavior Report Form to include a section for the nurse to document his/her assessment following a restraint. The Director of Nursing will review the revised form and documentation requirements with the nurses. The revised form will be implemented July 7, 2015.
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07/05/2015
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | The "Rights" forms, signed by Individual #1 on 12/9/13, and Individual #2 on 11/12/14, did not state the full rights per regulation 33(e) regarding privacy and regulation 33(j) regarding voting.
Per 6400.33(e), "An individual has the right to privacy in bedrooms, bathrooms and during personal care." Individual #1 and Individual #2's signed statements include "Each individual will be given privacy during treatment and care of personal needs."
Per 6400.33(j), "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." Individual #1 and Individual #2's signed statement does not include this statement.
| Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | The Quality Assurance Director revised the Client Rights to include "each individual has the right to privacy in bedrooms, bathrooms, and during personal care" and "each individual who is of voting age has the right to vote and will be assisted to register and vote in the elections." The Program Specialist will have client #1 and #2 and/or parent/guardian sign the revised rights by January 6, 2015. The Administrative Assistant will send the revised Client Rights to all clients and/or parent guardian by January 15, 2015. The Program Specialist will ensure the Client Rights are reviewed and the Acknowledgement Form signed by the client and/or parent/guardian annually and filed in the client's Program Book. |
12/29/2014
| Implemented |
| 6400.71 | The telephone numbers posted on or by each telephone did not include the number for the poison control center and the nearest hospital. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The Program Specialist revised the emergency phone numbers to include the numbers for poison control and the nearest hospital on 12/2/14. The Monthly Facility Inspection Form was revised to include "emergency phone numbers with correct numbers posted" on 12/24/2014. The House Manager or Team Leader will complete the Monthly Facility Checklist monthly. Identified issues are corrected and a report is provided to the Health & Safety Committee. |
12/29/2014
| Implemented |
| 6400.81(k)(6) | Individual #3's bedroom did not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | The Program Specialist purchased and installed the mirror in client #3's bedroom on 12/2/2014. This was a newly licensed facility. The Residential Director revised the New Facility Timeline Checklist Form to include "ensure all clients have the required bedroom furniture including a mirror" on 12/24/2014 . The Program Specialist will ensure that that New Facility Time Line is completed for all new Facilities prior to client's being admitted. |
12/29/2014
| Implemented |
| 6400.103 | The written emergency evacuation procedures do 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.
| The Quality Assurance Director revised the Emergency Evacuation Plan on 12/24/14 to include that the means of transportation will be by Agency and Staff vehicles and that the emergency shelter location are the Avalon Hotel on 16 West 10th Street, Erie, PA 16501, client family member's, or staff member's homes. The revised Emergency Evacuation Plan will be distributed to all group homes by january 1, 2015. |
12/29/2014
| Implemented |
| 6400.106 | The furnace has not been inspected and cleaned for several years by a professional furnace cleaning company or trained staff person. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The Maintenance Manager will schedule the furnace cleaning and inspection with a professional cleaning company by January 16, 2015. The Maintenance Manager will schedule the cleaning and inspections to be done by a professional cleaning company annually. The Program Specialist will receive a copy of the cleaning and inspection reports to ensure they were done by the professionally cleaning company annually. |
12/29/2014
| Implemented |
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