|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 is diagnosed with a Seizure disorder, Generalized Idiopathic seizures, takes daily medications for seizures and sees a neurologist for seizure medication reviews and current seizure activity. On 1/14/18 the individual's neurologist indicated that the individual needed to be seen due to "possible seizure activity." The individual's record did not include a seizure log or note to indicate what possible seizure activity occurred that required the need for the neurologist visit.
-According to the individual's prescribed Clonazepam medication label, the medication is ordered to be administered twice a day as needed for Anxiety or Seizures. There was no documentation to specify how or when the Clonazepam is to be administered for seizure activity.
-The residential agency did not have a seizure protocol for Individual #1. There was an agency on-call protocol for when to call 911. The guidelines included in the on-call protocol, indicate that in a medical emergency staff must call 911 first, then contact on-call staff. The protocol defines a medical emergency as a seizure if the person does not have a seizure disorder or a seizure that lasts longer than usual. The agency does not have a seizure protocol for the individual or any document to indicate normal or unusual seizure activity for the individual. There is also no documentation to indicate that any staff working in the home with Individual #1, received training on the on-call protocol and it's guidelines for when to call 911. There is no documentation to indicate any staff working with Individual #1 received training on the individual's seizure disorder, their specific seizure types, or what seizures may look like for the individual.
-Residential staff documented in the individual's record a few occasions of seizure activity. Staff documented on 5/27/18 at 7:45pm, the individual had a 30 second seizure, 5/30/18 at 4:15pm a 2 minute seizure but staff left the individual sit in a room for 5 minutes after they noticed the individual was "pursing lips" and on 12/27/18 at 4:45pm a 10 minute seizure. The individual did not go to the hospital after any of these documented seizures, per agency staff and Enterprise Incident Management (EIM) where providers/agencies report incidents. 911 was never called as it should have been per the on-call protocol. The individual's neurologist also wasn't notified of these seizure events.
- The individual has over 30 noted medication, environmental and food allergies. The individual is prescribed multiple allergy medications per their Individual Support Plan (ISP). According to the ISP, the individual is to take Benadryl, All Day Allergy, Azelastin, Flonase, Epi-Pen, and eye drops. The medications at the home that indicated to administer for allergic reactions were Epinephrine and Diphenhydramine. The individual's record does not include information or a protocol to follow for how to administer the allergy medications, when to administer the medications, which allergy medication needs to be administered first, when to call 911, when to notify the individual's doctor, what are signs and symptoms of the individual's specific allergic reactions to notice, etc.
-One of the individual's allergy medications, Diphenhydramine, indicated to administer 1 capsule after ingesting food which the individual is allergic to; max 2 capsules in 24 hours. According to 4/23/18 allergy list, the individual is to limit soybean, strawberry and wheat to 3 times a week. The agency is feeding the individual these specific foods that the individual has allergic sensitivities/allergies to and tracking when they give the foods to the individual weekly. However, the individual's Diphenhydramine indicates to administer the medication after ingesting a food which the individual is allergic to. The Diphenhydramine is not being administered.
(page 1, continued on next page) | 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. | PRN protocol, which includes seizures was developed and signed by neurologist Dr. Graf on 2/27/19, staff trained on 3/5/19. Attachment #12 pg. 30 of 35, pg. 31 of 35, pg. 32 of 35, pg. 33 of 35, pg. 34 of 35, pg. 35 of 35. Staff were retrained in On Call Procedures/Guidelines on 3/19/19. Attachment #17 pg. 1 of 8, pg. 2 of 8, pg. 3 of 8, pg. 4 of 8, pg. 5 of 8 pg. 6 of 8, pg. 7 of 8, pg. 8 of 8. Allergy protocol was developed and signed by individual #1s ENT 2/13/19. Attachment #12 pg. 7 of 35, pg. 8 of 35, pg. 9 of 35, pg. 10 of 35, pg. 11 of 35, pg. 12 of 35, pg. 13 of 35, pg. 14 of 35, pg. 15 of 35. Staff received training in allergies and allergy protocol on 3/5/19. Attachment #12 pg. 29 of 35. BM protocol was updated 2/12/19 by individual #1 PCP and Magnesium Citrate order updated to match BM protocol. Staff received training in individual #1 BM protocol and Fatal 4 on 3/5/19. Attachment #17 pg. 6 of 8, pg. 7 of 8, pg. 8 of 8. Staff received retraining in CSG Policy and Procedure for Medication Administration on 3/19/19. Attachment #9 pg. 1 of 6, pg. 2 of 6, pg. 3 of 6, pg. 4 of 6, pg. 5 of 6, pg. 6 of 6. Staff received retraining in individual #1 restrictive behavior plan and how to track behaviors. Attachment #12 pg. 34 of 35, pg. 35 of 35. All staff, Program Supervisors, Program Managers, Program Specialists will be retrained in the requirements of regulation 16 and CSG Policy and Procedure for Abuse and Neglect by 5/15/19. |
05/15/2019
| Implemented |
| 6400.16 | (page 3) There also wasn't documentation to indicate that the individual's documented anxiety behaviors subsided anytime from 1:15-3:20am on 10/6/17. The individual's Clonazepam wasn't administered until 3:20 am. The individual's behaviors occurred longer than 5 minutes. There is no documentation to indicate that staff used the strategies identified in the individual's bsp to calm the individual down, as they should have per the IDD protocol.
-Staff #4 and #5 documented that the individual's anxiety behavior on 2/1/19 occurred for longer than 5 minutes and there was no attempt to admin the prescribed as needed Clonazepam per medication label instructions and anxiety protocol. The 2/1/19 staff note indicated at 5pm there was self-injurious behaviors, screaming, physical aggression, and escalation "at Walmart one staff member noticed a sign of escalation. While putting items in page the individual started screaming. Staff verbally redirected the individual to use their words. With no success. Became physical with other staff. Using nappi skills staff added the individual's back pack and cart to their hands. Assisted safety to the car. While walking to car, the individual hit head, got them safely to the car and continued SIBs (self-injurious behaviors). Got home from Walmart, screamed and got physical with staff at home." | 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. | PRN protocol, which includes seizures was developed and signed by neurologist Dr. Graf on 2/27/19, staff trained on 3/5/19. Attachment #12 pg. 30 of 35, pg. 31 of 35, pg. 32 of 35, pg. 33 of 35, pg. 34 of 35, pg. 35 of 35. Staff were retrained in On Call Procedures/Guidelines on 3/19/19. Attachment #17 pg. 1 of 8, pg. 2 of 8, pg. 3 of 8, pg. 4 of 8, pg. 5 of 8 pg. 6 of 8, pg. 7 of 8, pg. 8 of 8. Allergy protocol was developed and signed by individual #1s ENT 2/13/19. Attachment #12 pg. 7 of 35, pg. 8 of 35, pg. 9 of 35, pg. 10 of 35, pg. 11 of 35, pg. 12 of 35, pg. 13 of 35, pg. 14 of 35, pg. 15 of 35. Staff received training in allergies and allergy protocol on 3/5/19. Attachment #12 pg. 29 of 35. BM protocol was updated 2/12/19 by individual #1 PCP and Magnesium Citrate order updated to match BM protocol. Staff received training in individual #1 BM protocol and Fatal 4 on 3/5/19. Attachment #17 pg. 6 of 8, pg. 7 of 8, pg. 8 of 8. Staff received retraining in CSG Policy and Procedure for Medication Administration on 3/19/19. Attachment #9 pg. 1 of 6, pg. 2 of 6, pg. 3 of 6, pg. 4 of 6, pg. 5 of 6, pg. 6 of 6. Staff received retraining in individual #1 restrictive behavior plan and how to track behaviors. Attachment #12 pg. 34 of 35, pg. 35 of 35. All staff, Program Supervisors, Program Managers, Program Specialists will be retrained in the requirements of regulation 16 and CSG Policy and Procedure for Abuse and Neglect by 5/15/19. |
05/15/2019
| Implemented |
| 6400.16 | (page 2) There isn't documentation from a physician indicating to not to give the medication after the individual ingests certain food allergies.
-According to the medication label, the individual is prescribed "Magnesium Citrate lemon MCKE, use if no medium sized bm (bowel movement) for 3 days. Drink 5 oz by mouth 1 time, if bowels don't move in 1 hour, drink rest." The BM protocol in the individual's record indicates "if no bm in 3 days, follow protocol and admin ½ bottle of mag cal by 4pm on third day, if no bm (med or large) admin other ½ mag cal." The medication label and protocol to not match. The protocol and medication label also do not address if the second dose of medication isn't effective, what staff are to do. The medication label does not indicate the number of ounces that are to be consumed during the second administration of Magnesium Citrate if needed.
-According to the individual's bm chart, staff documented the individual had a large bm during the evening shift on 1/16/19 and that a magnesium citrate was administered at 3pm and 4pm on 1/19/19. It was documented that the individual did not have a bm until the day shift on 1/20/19. There was no documentation to indicate the individual's physician was notified to determine if the individual needed to be seen. The bm charts also do not indicate a time the bm occurred. Therefore, staff can not determine when the 3 days without having a bm have passed to know when to administer Magnesium Citrate per the medical label.
-The individual's December 2018 bm chart indicated a medium bm happened during the day shift on 12/22/18 and that staff administered magnesium citrate during the evening shift on 12/24/18; too soon. There was a note in the record indicating that when Staff #3 came on shift on 12/24/18, another staff told them that the individual needed magnesium citrate administered by 4pm that day per the protocol. Staff #3 administered the magnesium citrate to the individual at 3:23pm prior to reviewing the individual's medication log and medication protocol.
-Staff also noted the individual had a medium bm during the evening (second) shift on 12/27/18 and another medium bm not occurring until dayshift (first) on 12/31/18. There was no indication on any log that magnesium citrate was administered per the medication label's instructions.
-The individual had a documented medium bm on dayshift 12/31/18 and not another medium or large bm until evening/second shift on 1/4/19. Staff did document that magnesium was administered to the individual on the evening/second shift on 1/3/19; however this was still passed the 3 day administration instructions. There was another documented medium bm on the evening/second shift 1/16/19 and not another medium or large bm until the night shift on 1/20/19. The magnesium citrate was not administered as prescribed.
- Individual #1 has an IDD protocol and procedure for administration of Clonazepam as needed for Anxiety indicated that if symptoms of Anxiety. The protocol defined Anxiety as an excessive activity and internal restlessness which may result in screaming, physical aggression towards others and/or self-injurious behavior. The protocol indicated that if Anxiety persist for at least 5 minutes and is unable to be managed by the individual themselves or by staff implementation of strategies outlined in the behavior support plan (bsp) , staff should contact the as needed contact person. The as needed contact person should be APD (management oversight staff). If APD is unavailable, call on-call person and they can accept or decline the use of as needed Anxiety medication. According to daily documentation from staff, on 10/6/17 staff started indicating around 1:15 am that the individual was having vocalizations, getting in and out of bed, and having restlessness. Also a note on 2:25am on 10/6/17 indicated the individual was having vocalizations since 2am.
(continued on next page) | 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. | PRN protocol, which includes seizures was developed and signed by neurologist Dr. Graf on 2/27/19, staff trained on 3/5/19. Attachment #12 pg. 30 of 35, pg. 31 of 35, pg. 32 of 35, pg. 33 of 35, pg. 34 of 35, pg. 35 of 35. Staff were retrained in On Call Procedures/Guidelines on 3/19/19. Attachment #17 pg. 1 of 8, pg. 2 of 8, pg. 3 of 8, pg. 4 of 8, pg. 5 of 8 pg. 6 of 8, pg. 7 of 8, pg. 8 of 8. Allergy protocol was developed and signed by individual #1s ENT 2/13/19. Attachment #12 pg. 7 of 35, pg. 8 of 35, pg. 9 of 35, pg. 10 of 35, pg. 11 of 35, pg. 12 of 35, pg. 13 of 35, pg. 14 of 35, pg. 15 of 35. Staff received training in allergies and allergy protocol on 3/5/19. Attachment #12 pg. 29 of 35. BM protocol was updated 2/12/19 by individual #1 PCP and Magnesium Citrate order updated to match BM protocol. Staff received training in individual #1 BM protocol and Fatal 4 on 3/5/19. Attachment #17 pg. 6 of 8, pg. 7 of 8, pg. 8 of 8. Staff received retraining in CSG Policy and Procedure for Medication Administration on 3/19/19. Attachment #9 pg. 1 of 6, pg. 2 of 6, pg. 3 of 6, pg. 4 of 6, pg. 5 of 6, pg. 6 of 6. Staff received retraining in individual #1 restrictive behavior plan and how to track behaviors. Attachment #12 pg. 34 of 35, pg. 35 of 35. All staff, Program Supervisors, Program Managers, Program Specialists will be retrained in the requirements of regulation 16 and CSG Policy and Procedure for Abuse and Neglect by 5/15/19. |
05/15/2019
| Implemented |
| 6400.22(d)(2) | REPEAT from 9/18/17 annual inspection: Individual #1's record did not include an up to date funds record for the amount of money the individual had in their itunes account. Apparently 25 dollars was added into the Individual's account on 1/31/19 and 2/1/19, two separate occasions. | (2) Disbursements made to or for the individual.
| : Individual #1s Cash, Receipts and Disbursements (CRD) forms were updated to reflect missing transactions from 1/31/19 and 2/1/19. CRDs will be reviewed weekly by Program Supervisors and audited weekly by the Program Managers to ensure funds records are up to date and accurate. All CRD¿s will be reviewed by 5/31/19 to insure compliance companywide. All staff, Program Supervisors, Program Managers, Program Specialists will be retrained in the requirements of regulation 22 D 2 and CSG¿s Policy on Cash Receipts and Dispursements by 5/15/19. See updated Cash Receipts and Dispursements form. |
05/31/2019
| Implemented |
| 6400.44(b)(18) | REPEAT from 9/18/17 annual inspection: At the time of licensing on 2/5/19, none of the staff working with Individual #1 were trained on the individual's specific type of seizures. There was also no documentation to indicate that any staff working with Individual #1 were trained on the individual's specific 38 allergies, how to respond to the allergic reaction, or the change in allergies throughout the year as they occurred. Some staff electronically signed a document that indicated the specific staff read Individual #1's Individual Support Plan (ISP), Assessment, and restrictive plan. There was never a training provided by the program specialist to the direct support staff on the individual's specific needs when the staff electronically signed that they read some of the individual's documents. As referenced in violations 6400.213(11), 6400. 181(e)(9), 6400.181(e)(4), 6400.141(c)(13), and 6400.141(c)(15), these documents that may have only been reviewed by staff (without a training) did not include the most recent and up to date health and safety information that would be required to know prior to working with Individual #1. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | All Staff at the home received face to face training by the Program Specialist on individual #1s seizures, his seizure protocol, current allergies and allergy protocols on 3/5/19. A CSG nurse will complete a review of this record to insure that all health and safety needs are being met and will visit the home to observe and meet with the staff to insure that staff demonstrate an understanding of how to care for the individual. This review will be completed and documented in the electronic health record by June 30, 2019. Program Specialists will review all individual health and safety needs by 5/31/19 and will insure that all necessary trainings for direct service workers have been complete and that we are in compliance companywide. All Program Specialists will be retrained in the requirements of regulation 44 B 18 by 5/15/19. See training sheets for seizure, seizure protocol, current allergies and allergy protocols. |
06/30/2019
| Implemented |
| 6400.46(a) | REPEAT from 9/18/17 annual inspection: During the onsite inspection on 2/7/19, it was discovered that Individual #1's itunes account was not kept current because previous employees who worked with the individual, Staff #8 and #9, did not how to log the individual's iTunes gift cards and financial information relating to the individual's iTunes account. These two staff did not receive training/orientation to the house and the daily operations of the home which would include keeping an up to date financial log of Individual #1's finances and iTunes account. | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | Staff at the home were retrained in client funds and gift cards and specifically how to log the itunes account by the fiscal specialist on 3/5/19. Program Supervisors, Program Managers, Program Specialists and Mentors will be retrained on the IDD New Employee Checklist, and the requirements and timeframes in which items must be completed prior to an employee working with individuals by 5/15/19. A workgroup will be established to review the current staff orientation process and will determine if improvements to the process should be made to meet compliance The workgroup will complete their review by July 31, 2019. Program Supervisors, Program Managers, and Program Specialist will be retrained in the requirements of regulation 46 A by 5/15/19. See client funds and gift cards training sheet. |
07/31/2019
| Implemented |
| 6400.67(a) | Individual #2's bathroom did not have a toilet paper holder to keep the toilet paper off of the sink/countertop. The middle, spring loaded apparatus of the toilet paper holder was missing from the devise. | Floors, walls, ceilings and other surfaces shall be in good repair. | Staff replaced toilet paper holder was purchased and installed on 3/11/19. The Program Supervisor will provide ongoing coaching to staff surrounding the need to ensure that all surfaces are in good repair. All DSP staff and Program supervisors will be required to report any physical site or safety concerns directly to the Program Manager via the home webex room. The Program Manager will be responsible to complete a quarterly inspection of the home to insure compliance with all physical site and safety requirements. A checklist for all physical site and safety requirements will be developed by 5/15/19 and all Program Managers will be trained on the use of the checklist and the quarterly inspection requirements by 5/31/19. The first quarterly inspection review by the Program Manager will be completed by July 31, 2019. Program Directors in coordination with CSG¿s Facility and Property Management team will complete a walkthrough of each home in CSG to insure agency wide compliance with all physical site and safety requirements utilizing CSG¿s Risk Management Checklist. All walkthroughs will be completed by July 31, 2019. All staff, Program Supervisors, Program Managers and Program Specialists will be trained in regulation 67 (a) by 5/15/2019. See photo of toilet paper holder |
07/31/2019
| Implemented |
| 6400.72(b) | REPEAT from 9/18/17 annual inspection: The garage egress door would not shut without intense force. The inspector had to use their body weight and shove the door closed. | Screens, windows and doors shall be in good repair. | Contractors fixed the door on 2/28/19 and it locks and opens as it should. The Program Supervisor will provide ongoing coaching to staff surrounding the need to ensure that all screens doors and windows are in good repair All DSP staff and Program supervisors will be required to report any physical site or safety concerns directly to the Program Manager via the home webex room. The Program Manager will be responsible to complete a quarterly inspection of the home to insure compliance with all physical site and safety requirements. A checklist for all physical site and safety requirements will be developed by 5/15/19 and all Program Managers will be trained on the use of the checklist and the quarterly inspection requirements by 5/31/19. The first quarterly inspection review by the Program Manager will be completed by July 31, 2019. Program Directors in coordination with CSG¿s Facility and Property Manager will complete a walkthrough of each home in CSG to insure agency wide compliance with all physical site and safety requirements utilizing CSG¿s Risk Management Checklist. All walkthroughs will be completed by July 31, 2019. All staff, Program Supervisors, Program Managers and Program Specialists will be trained in regulation 72 (b) by 5/15/2019. See photo of repaired door and invoice for repair. |
07/31/2019
| Implemented |
| 6400.141(c)(3) | REPEAT from 9/18/17 annual inspection: Individual #1's 4/23/18 physical examination form did not include a list of immunizations. The field for Tetanus immunization was blank. A list of immunizations was not attached to the physical examination form. | 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. | Individual #1s physical exam was updated with immunization information, including Tetanus. Attachment #12, pg. 18 of 35, pg. 19 of 35. All staff, Program Supervisors, Program Managers, Program Specialists will be retrained in the requirements of regulation 141 C 3 by 5/15/19. Individual record reviews will be completed by the Program Specialists for all individuals by 5/31/19 to ensure physical exams include immunization information. |
03/21/2019
| Implemented |
| 6400.141(c)(13) | Individual #1's 4/23/18 physical examination form only indicated "food allergies" but didn't list specific food allergies nor where they attached to the form. The individual has an extensive list of food, environmental, and medication allergies (38 total) that may/may not change throughout the year. The 4/23/18 physician's print out indicated "allergies to azithromycin, Keflex, Bactrim, Risperdal-seizures, foods, erythromycin, seasonal, allegra." | The physical examination shall include: Allergies or contraindicated medications. | Staff will be retrained in the requirements of regulation 141 C 13. Individual #1's physical exam was updated to include an attached list of allergies. Attachment #12, pg. 18 of 35, pg. 19 of 35, pg. 20 of 35. All staff, Program Supervisors, Program Managers, Program Specialists will be retrained in the requirements of regulation 141 C 13 by 5/15/19. Individual record reviews will be completed by the Program Specialists for all individuals by 5/31/19 to ensure physical exams include allergies. |
03/21/2019
| Implemented |
| 6400.141(c)(15) | Individual #1's 4/23/18 physical examination from did not include specific instructions for the individual's diet. According to documents in the individual's record, they have some sensitivities and allergies to foods. Some foods the individual is to avoid entirely, some they can have up to 3 times a week. This was not indicated on the individual's 4/23/18 physical examination form. | The physical examination shall include:Special instructions for the individual's diet. | Individual #1s physical exam was updated with special instructions for the individual's diet. Attachment #12, pg. 18 of 35, pg. 19 of 35. All staff, Program Supervisors, Program Managers, Program Specialists will be retrained in the requirements of regulation 141 C 15 by 5/15/19. Individual record reviews will be completed by the Program Specialists for all individuals by 5/31/19 to ensure physical exams include special instructions for the individuals diet. |
03/21/2019
| Implemented |
| 6400.144 | REPEAT from 9/18/17 annual inspection: On 10/10/17, Individual #1's neurologist indicated to "return in about 6 months, around 4/10/18." The individual didn't return to their neurologist until 5/15/18. There was no documentation in their record to indicate why the return appointment was not completed as indicated by the physician.
--Individual #1's neurologist prescribed Clonazepam 1mg 3 times a day as needed from 5/15/18 until 11/15/18. On 11/15/18 the individual's neurologist indicated on an agency appointment form to now administer the medication 4 times a day as needed. However, on the neurologist's 11/15/18 appointment print out, he indicated to change the administration of Clonazepam 1mg as needed to 2 times a day; which was already the current dosage prescribed to the individual. There was no documentation in the record to indicated what dosage the individual should be administered. The individual's as needed medication protocol for Clonazepam never changed the administration dosage of Clonazepam.
-The individual has over 30 noted medication, environmental and food allergies. The individual is prescribed multiple allergy medications per their Individual Support Plan (ISP). According to the ISP, the individual is to take Benadryl, All Day Allergy, Azelastin, Flonase, Epi-Pen, and eye drops. The individual's record does not include information or a protocol to follow for how to administer the allergy medications, when to administer the medications, which allergy medication needs to be administered first, when to call 911, when to notify the individual's doctor, what are signs and symptoms of the individual's specific allergic reactions to notice, etc.
-The doctor indicated on a 11/15/18 appointment form to continue Bactroban ointment daily for 6 months. The doctor's print out from 11/15/18 indicated to administer the medication 1 time per day for 30 days. There is no documentation to indicate which order was correct. The agency administered the medication daily for 6 months.
(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.
| Individual #1 was seen by his neurologist on 2/18/19 and has another scheduled appointment for 5/23/19. Printout from 11/15/18 Bactroban order provided and he was to use one time daily until next visit as directed. When individual #1 was seen by the neurologist on 2/18/19, the Clonazepam prn order was clarified and the PRN protocol was also updated and signed by neurologist on 2/27/19. Allergy protocol was developed and signed by ENT on 2/13/19. On 2/27/19 individual #1 was seen by his dietician who recommended an 1800 calorie diet. Individual #1s physical examination form was updated, assessment was updated on 3/21/19 along with updates sent to SC on 3/28/19. Staff received training in the Allergy Protocol on 3/5/19, Seizures and Seizure and PRN Protocol on 3/5/19, Restrictive Plan Review for Individual #1 on 3/26/19, Tracking Behaviors and regulation 144 on 3/26/19. Attachment #12 Pg. 1 through pg. 35 of 35. All staff, Program Supervisors, Program Managers, Program Specialists will be retrained in the requirements of regulation 144 by 5/15/19. |
05/15/2019
| Implemented |
| 6400.144 | (page 2)
-The individual's 2018 assessment indicated on 3/27/18, the individual's primary care physician (pcp) would like the individual to cut back on carbs. They were to only have ¼ cup to ½ cup of carbs per serving per meal. The agency confirmed this was not being monitored by staff, documented, or tracked.
-Individual #1 has an IDD protocol and procedure for administration of Clonazepam as needed for Anxiety indicated that if symptoms of Anxiety. The protocol defined Anxiety as an excessive activity and internal restlessness which may result in screaming, physical aggression towards others and/or self-injurious behavior. The protocol indicated that if Anxiety persist for at least 5 minutes and is unable to be managed by the individual themselves or by staff implementation of strategies outlined in the behavior support plan (bsp) , staff should contact the as needed contact person. The as needed contact person should be APD (management oversight staff). If APD is unavailable, call on-call person and they can accept or decline the use of as needed Anxiety medication. According to daily documentation from staff, on 10/6/17 staff started indicating around 1:15 am that the individual was having vocalizations, getting in and out of bed, and having restlessness. Also a note on 2:25am on 10/6/17 indicated the individual was having vocalizations since 2am. There is no documentation in the individual's record to indicated there was any attempts to contact the on-call or APD staff until 3:20am to receive approval to administer the as needed anxiety medication. There also wasn't documentation to indicate that the individual's documented anxiety behaviors subsided anytime from 1:15-3:20am on 10/6/17. The individual's Clonazepam wasn't administered until 3:20 am. The individual's behaviors occurred longer than 5 minutes. There is no documentation to indicate that staff used the strategies identified in the individual's bsp to calm the individual down, as they should have per the IDD protocol. | 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 was seen by his neurologist on 2/18/19 and has another scheduled appointment for 5/23/19. Printout from 11/15/18 Bactroban order provided and he was to use one time daily until next visit as directed. When individual #1 was seen by the neurologist on 2/18/19, the Clonazepam prn order was clarified and the PRN protocol was also updated and signed by neurologist on 2/27/19. Allergy protocol was developed and signed by ENT on 2/13/19. On 2/27/19 individual #1 was seen by his dietician who recommended an 1800 calorie diet. Individual #1s physical examination form was updated, assessment was updated on 3/21/19 along with updates sent to SC on 3/28/19. Staff received training in the Allergy Protocol on 3/5/19, Seizures and Seizure and PRN Protocol on 3/5/19, Restrictive Plan Review for Individual #1 on 3/26/19, Tracking Behaviors and regulation 144 on 3/26/19. Attachment #12 Pg. 1 through pg. 35 of 35. All staff, Program Supervisors, Program Managers, Program Specialists will be retrained in the requirements of regulation 144 by 5/15/19. |
05/15/2019
| Implemented |
| 6400.163(c) | REPEAT from 9/18/17 annual inspection: Individual #1's 10/18/17, 1/10/18, 4/4/18, 6/28/18, 9/19/18, and 12/12/18 medication review with their psychiatrist does not indicate the reason for prescribing the individual's Chlorpromazine or daily Clonazepam. The reviews also did not indicate that Clonazepam is a daily medication and the dosage that is to be administered daily. The reviews only indicated Clonazepam was prescribed as needed for anxiety.
-According to agency staff, the individual's psychiatrist who performs the medication reviews, doesn't prescribe Clonazepam to the individual. Therefore the psychiatrist doesn't review the psychotropic medication at the medication reviews, even though the "as needed Clonazepam" was written on the form. There also wasn't documentation to indicate that Clonazepam, daily medication, was being reviewed with a licensed physician at least every three months due to the medication being prescribed for Anxiety.
-Individual #1's neurologist indicated on 5/15/18 that Klonopin, 1mg as needed 2 times a day is being prescribed instead of 3 times a day. According to the psychiatric medication reviews, Clonazepam was still listed as "1mg as needed, 3 times a day" not the current prescribed dosage. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | A psychiatric medication review was completed by psychiatrist for individual #1 on 3/6/19 for Chlorpromazine, Benztropine and Doxepin. Psychiatrist for individual #1 will not review the Clonazepam/Klonopin since it is prescribed by his neurologist. Program Supervisor made with neurologist Dr. Graf for 5/23/19 to complete a review of Clonazepam/Klonopin (daily and PRN) and informed office of need of individual #1 to see neurologist every three months for these reviews. Attachment #10 pg. 1 of 7, pg. 2 of 7, pg. 3 of 7, pg. 4 of 7, pg. 5 of 7, pg. 6 of 7, pg. 7 of 7. All staff, Program Supervisors, Program Managers, Program Specialists will be retrained in the requirements of regulation 163 C by 5/15/19. |
05/15/2019
| Implemented |
| 6400.164(a) | REPEAT from 9/18/17 annual inspection: Individual #1's script and written doctor's order on 10/22/18 indicated start "Bactroban (Muprocin) Ointment 2%, 2 times daily to affected area for 21 days." The October 2018 medication log indicated "Muprocin 2% ointment external, 2 times per day, daily" did not match the script. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | Program Manager retrained staff on CSG¿s Policy and Procedure for Medication Administration on 3/19/19. Attachment #9 pg. 1 of 6, pg. 2 of 6, pg. 3 of 6, pg. 4 of 6, pg. 5 of 6, pg. 6 of 6. All staff, Program Supervisors, Program Managers, Program Specialists will be retrained on the requirements of regulation 164A by 5/15/19. |
05/15/2019
| Implemented |
| 6400.167(b) | -Individual #1's script and written doctor's order on 10/22/18 indicated start "Bactroban (Muprocin) Ointment 2%, 2 times daily to affected area for 21 days." The October 2018 medication log indicated "Muprocin 2% ointment external, 2 times per day, daily" did not match the script. The staff administered the medication to Individual #1 two times per day from 10/23/18 until 11/12/18, then stopped administration.
-On 12/3/17 Individual #1's medications, Clonazepam, Chlorpromazine and Benzatropine, were not administered at 4pm as prescribed. Staff indicated on an incident report that staff forgot to administer the meds at 4pm. Per incident report, the individual's doctor allowed administration of the three missed medications to be administered at 5:43pm. This was outside regulatory time frame allowed. There was no indication of a new order that was faxed from the doctor to change the time of administration for all three medications. Per incident report, the doctor gave a verbal order to a direct support staff who is not a nurse. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Program Manager retrained staff on CSG¿s Policy and Procedure for Medication Administration on 3/19/19. Attachment #9 pg. 1 of 6, pg. 2 of 6, pg. 3 of 6, pg. 4 of 6, pg. 5 of 6, pg. 6 of 6. All staff, Program Supervisors, Program Managers, Program Specialists will be retrained on the requirements of regulation 167B by 5/15/19. |
05/15/2019
| Implemented |
| 6400.181(e)(4) | -Individual #1's 4/23/18 assessment doesn't include the individual's need for 2 hour nightly checks when they are in their room and sleeping. According to staff and the individual's Individual Support Plan (ISP), this 2 hour nightly check has been in place since the last licensing conducted on 9/18/17 and currently is still in place.
-Currently the individual's assessment indicates they need 2:1, staff to individual ratio, at all times and can only be decreased when the individual is sleeping in their bedroom. Currently the home only has one sleep and one awake staff during the night shift and two individuals residing in the home. It is noted in the individuals record that the individual does get up during the night and is awake for a few hours sometimes. Two awake staff to one individual ratio is not provided during the nighttime hours if the individual is awake for a few hours. The individual's supervision level during the night time hours when they are awake is not addressed in the individual's assessment. | The assessment must include the following information: The individual's need for supervision.
| The assessment was updated by the Program Specialist on 3/21/19 to reflect that the individual is to have 2 staff during the day and that the individual is safe to have 1 staff during the overnight hours while awake or asleep and clarifications was added regarding supervision needs for overnight checks. An email was sent by the Program Specialist to the SC on 3/28/19 for updates to individual #1¿s ISP to clarify and reflect these supervision needs. A review of all records will be completed by the Program Specialist by 5/31/19 to insure that the assessments are complete and accurate companywide. Program Directors will complete a random review of an assessment to insure it meets all requirements on a quarterly basis and will review their findings with the Program Specialist. Any necessary corrections will then be made by the Program Specialist. All staff will be trained on the updates to the individuals supervision level by 5/15/19. All Program Specialists will be retrained in the requirements of regulation 181 E 4 by 5/15/19. See updated assessment showing the correct need for supervision, see copy of email to SC requesting updates to the ISP. |
05/31/2019
| Implemented |
| 6400.181(e)(9) | Individual #1's 4/23/18 assessment indicated the lifetime medical history was attached. In the attached lifetime medical history, it included some of the individual's functional and medical limitations, however, not all of them. The attached form only listed "food allergies" as a limitation but did not include the extensive list of food allergies or that food allergies may change for the individual throughout the year. At the time of the inspection on 2/5/19, the individual had documented 38 total medical, food and environmental allergies that altered their daily life.
-The attached lifetime medical history also didn't include the individual's last neurologist appointment on 1/14/18 where they were seen due to seizure activity. The recent seizure activity was a medical limitation that was not addressed. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The lifetime medical history was updated on 3/20/19 to include all allergies, information regarding allergies historically changing and the 1/14/19 neurology visit and the assessment was updated on 3/21/19 with the lifetime medical history attached. Attachment #8 pg. 1 of 6, pg. 2 of 6, pg. 3 of 6, pg. 4 of 6, pg. 5 of 6, pg. 6 of 6. Program Managers and Program Specialists will be retrained in the requirements of regulation 181(e)(9) by 5/15/19. Individual record reviews will be completed by the Program Specialists for all individuals by 5/31/19 to ensure the assessment includes documentation of the individual¿s disability, including functional and medical limitations. |
05/31/2019
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's 4/23/18 assessment didn't include their progress over the last 365 calendar days and current level in motor skills. The assessment only addressed the individual's progress and current level in communication skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | The assessment was updated by Program Specialist on 3/21/19 to reflect progress over the last 365 calendar days and current level in motor skills. Attachment #7 pg. 1 of 4, pg. 2 of 4, pg. 3 of 4, pg. 4 of 4. Program Specialists will be retrained in the requirements of regulation 181 e 13 ii by 5/15/19. Individual record reviews will be completed by the Program Specialists for all individuals by 5/31/19 to ensure the assessment includes the individual¿s progress over the last 365 days and current level in the motor and communication skills. |
05/31/2019
| Implemented |
| 6400.185(b) | -Individual #1's Individual Support Plan (ISP) indicates that the individual requires two staff available to them to ensure safety and implement behavior strategies. The individual's 4/23/18 assessment indicates that the individual needs 2:1, staff to individual ratio, at all times and that 2:1 ratio can only decrease when the individual is sleeping in their bedroom. Currently the home only has one sleep and one awake staff during the night shift and two individuals residing in the home. It is noted in the individuals record that the individual does get up during the night and is awake for a few hours sometimes during the night. Two awake staff to one individual ratio is not provided during the nighttime hours if the individual is awake for a few hours.
-Individual #1's 4/23/18 assessment indicates that they require alarms on all egress doors. The individual's ISP indicates that door alarms are in place to staff are alerted if the individual opens the door to go outside. During the onsite inspection of the home on 2/7/19, the egress door leading from the garage to the outside of the home or the garage doors, weren't equipped with a door alarm. | The ISP shall be implemented as written. | An email was sent to the SC on 3/28/19 for updates to individual #1¿s ISP to clarify and reflect his supervision needs. Attachment #6 pg. 1 of 3, pg. 2 of 3, pg. 3 of 3. Individual #1¿s assessment was updated by Program Specialist on 3/21/19. Attachment #7 pg. 1 of 4, pg. 4 of 4. Program Supervisors, Program Managers and Program Specialists will be retrained in the requirements of regulation 185B by 5/15/19. |
05/15/2019
| Implemented |
| 6400.195(a) | Individual #2 lives with Individual #1. Individual #1 has a restive plan in place to restrict access to food. However Individual #2 does not have a restrictive plan to restrict access to food and is currently unable to access the locked food in the home. All food is locked in a food pantry by a key lock and locked in the refrigerator and freezer by a key lock. Individual #2 can not operate the key lock to access the food, per provider. | For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to use of restrictive procedures.
| Magnetic lock was installed on the kitchen cabinet doors, which allows access to food for individual #2. We are currently working on use of the key fob and magnetic lock with individual #2. Program Specialist emailed SC to update individual #1 ISP regarding magnetic lock. Attachment #5 pg. 1 of 5, pg. 2 of 5, pg. 3 of 5, pg. 4 of 5, pg. 5 of 5. All staff, Program Supervisors, Program Managers, Program Specialists will be retrained in the requirements of regulation 195 A by 5/15/19. |
05/15/2019
| Implemented |
| 6400.195(d) | Individual #1's current restrictive procedure plan, effective from 8/31/18-8/30/19, was not signed and dated by the program specialist, Staff #1. The restrictive procedure plan was not signed and dated by the chair person, Staff #2, until 1/10/19; after the plans effective from date. | The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months.
| An updated restrictive procedure plan has been signed and dated by Program Specialist and chairperson (Kent Young, Program Director) of the restrictive procedure review prior to implementation on 3/27/19. Attachment #4, pg. 1 of 2, pg. 2 of 2. Program Specialists and chairperson of the restrictive procedure review committee will be retrained in the requirements of regulation 195 D by 5/15/19. Individual record reviews will be completed by the Program Specialists for all individuals by 5/31/19 to ensure restrictive procedure plans are reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months. |
05/31/2019
| Implemented |
| 6400.195(f) | Individual #1's 8/14/18 restrictive procedure plan indicated that the refrigerator, freezer and pantry will be locked with the food in it. During the onsite inspection on 2/7/19, there were two standing freezers in the basement that were not locked and accessible. The basement door wasn't locked and the individual had access to the basement. | The restrictive procedure plan shall be implemented as written.
| Basement freezers do not need to be locked as individual #1 does not show any interest in entering the basement and it contains two deep freezers which contain raw meats and frozen foods that would not be ready to eat. The restrictive behavior plan has been updated to reflect this and an email sent to the SC to update the ISP. Attachment #3 pg. 1 of 5, pg. 2 of 5, pg. 3 of 5, pg. 4 of 5, pg. 5 of 5. Program Supervisors, Program Managers and Program Specialists will be retrained in the requirements of regulation 195 F by 5/15/19. |
05/15/2019
| Implemented |
| 6400.196(a) | Staff #6 and #7 have been working at the residential home with Individual #1, whom has a restrictive procedure plan in place, for a few years. There's no documentation that either staff received training in the use of and ethics of using restrictive procedures including the use of alternative positive approaches within the last 12 months. | If restrictive procedures are used, there shall be at least one staff person available when restrictive procedures are used who has completed training within the past 12 months in the use of and ethics of using restrictive procedures including the use of alternate positive approaches.
| Staff were retrained in NAPPI (Non-Abuse Psychological and Physical Intervention) on 4/2/19, which includes use of alternate positive approaches and use of ethics in restrictive procedures. Attachment # 2 pg. 1 of 9, pg. 2 of 9, pg. 3 of 9, pg. 4 of 9, pg. 5 of 9, pg. 6 of 9, pg. 7 of 9, pg. 8 of 9, pg. 9 of 9. Program Supervisors, Program Managers, Program Specialists will be retrained in the requirements of regulation 196 A by 5/15/19. |
05/15/2019
| Implemented |
| 6400.213(11) | Individual #1's most recently updated, 4/2/18 lifetime medical history in their record, indicated they should follow a 2200 calorie diet. The individual's 2018 physical examination form didn't include any dietary needs relating to calorie intake. The individual's Individual Support Plan (ISP) does not indicate that they should follow a 2200 calorie intake diet.
-Individual #1's electronic record listed allergies to: "Allegra, almond, apple, Bactrim, banana, barley, cantaloupe, carrot, cheddar cheese, Chickpea, corn, dust mites, erythromycin, garlic, grape, grass pollen, hazelnut, strawberry, orange, greenbean, tomatoe, soybean, onion, sweat potatoe, wheat, watermelon, peanut, plant pollen, tree pollen, wild rice, maple tree pollen, powder/cornstarch; medications; Erythromycin, Keflex, Bactrim, Risperdal, Allegra." The individual's ISP indicates the individual has to carry an Epi-pen for bee sting allergies. According to agency staff, the individual doesn't have a bee sting allergy. The individual's ISP also includes allergies to Risperidone, grass pollen, orchard pollen, white ash, ragweed, lamb's quarter, rye, fescue, bent top, cottonwood, elm, oak, cocklebur, sheep sorrel, pigweed, plantain, Alternaria beech, birch, hickory, sycamore, pears, papain, lettuce, mustard, green pepper, cantaloupe, coconut, pecan, potato, amaranth, oat, asparagus, and Ambien. The individual's 2018 physical examination doctor's print out only included allergies to "Azithromycin, Keflex, Bactrim, Risperdal-seizures, foods, Erythromycin, seasonal, Allegra."
-None of the individual's medications listed in the individual's ISP indicate that they are prescribed for a psychiatric diagnosis. According to the agency, the individual is prescribed medications for Intermittent Explosive Disorder (IED) and has a diagnosis of IED. According to some of the medication lists in the individual's record and a doctor's protocol, they are prescribed Clonazepam for Anxiety. The individual's ISP indicates they are prescribed Clonazepam and Thorazine for Autism. According to the individual's electronic medical records, Thorazine is prescribed for a Mood stabilizer.
-The medications included in the individual's ISP are not kept current to include all medications prescribed to the individual and why. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | In consulting with a dietician, it was clarified that individual #1 should be following an 1800 calorie diet. This was updated on his physical exam form, lifetime medical history and ISP. List of allergies updated on physical form, ISP, lifetime medical history and an allergy protocol was created. PRN protocol was updated to indicate medications needed for psychiatric treatment. A copy of the updated physical exam form, lifetime medical history, email to SC to update ISP and the allergy. Attachment #1, pg. 1 of 20, pg. 2 of 20, pg. 3 of 20, pg. 4 of 20, pg. 4 of 20, pg. 5 of 20, pg. 6 of 20, pg. 7 of 20, pg. 8 of 20, pg. 9 of 20, pg. 10 of 20, pg. 11 of 20, pg. 12 of 20, pg. 13 of 20, pg. 14 of 20, pg. 15 of 20, pg. 16 of 20, pg. 17 of 20, pg. 18 of 20, pg. 19 of 20, pg. 20 of 20. Program Supervisors, Program Managers and Program Specialists will be retrained in the requirements of regulation 213(11) by 5/15/19. Individual record reviews will be completed by the Program Specialists for all individuals by 5/31/19 to ensure the record includes content discrepancy in the ISP, the annual update or revision. |
05/31/2019
| Implemented |
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