| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | At the time of inspection there were two money pouches in the home identified as belonging to Individual #1. One money pouch contained $10, and the other money pouch contained $40. There was no documentation to illustrate when the money was deposited at the home or a record of the money being in the home. An up-to-date financial record that includes funds received by or deposited with the home shall be kept. | 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. | The center¿s finance director updated individual funds protocol to always include the availability of $25.00 in a single locked location, accessible to all staff members for use. (Attachment: Updated Individual Funds Protocol) |
05/30/2023
| Implemented |
| 6400.143(a) | Individual #1 was admitted into the program on 3/16/20. Records submitted indicate that the first dental appointment attended by Individual #1 was on 9/30/21. Individual #1 did not cooperate with the appointment as indicated by dentist entry "PT uncooperative-refer Geisinger Danville." Individual #1 was seen at Geisinger dental on 11/5/21. No work was completed. Notation on the 11/5/21 Geisinger visit form indicates that "PT place on OR wait list." Individual #1 was not trained in the need for health care. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | The individual is scheduled for 5/25/2023 with Geisinger Danville for dental anesthesia. 5/25/2023 was the first available appointment the dental provider had. |
05/25/2023
| Implemented |
| 6400.144 | Individual #1 was admitted into the program on 3/16/20. Notation in the Individual Support Plan (ISP) for Individual #1 last updated on 2/27/23 indicates that they wear corrective lenses and are seen by Dr. Davin Carl at the Northeast Eye Institute (NEI) Last documented exam was held on 9/11/18 with a notation of "As needed" Additional notation in the ISP indicates that "nei's policy for devereux is that both the resident and staff need to be vaccinated for covid when attending an appointment. Not all staff are vaccinated, so they are unable to take (Individual) for this evaluation." Individual #1 "Service Review Summary-Lifetime" created by provider documents that the glasses are an adaptive device used as well as "Client refuses to wear." Also noted "Last change in glasses/contact lenses prescription" section completed as "unknown." Since admission there are no documented attempts to complete a vision exam, determine "as needed" status or ensure proper staffing so that Individual #1 can be properly assessed.
Records submitted indicate that the first dental appointment attended by Individual #1 was on 9/30/21. Individual #1 did not cooperate with the appointment as indicated by dentist entry "PT uncooperative-refer Geisinger Danville." Individual #1 was then seen at Geisinger dental on 11/5/21. No work nor evaluations were completed. Notation on the 11/5/21 Geisinger visit form indicates that "PT place on OR wait list." Since the 9/30/21 appointment there were no documented additional attempts to schedule cleanings for Individual #1 or follow up with Geisinger regarding dental cleanings to be performed in the operating room. | 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.
| Upon admission Individual did not have corrective lenses that came with them. Currently NEI has lifted their strict COVID policy to now allow individuals to receive services regardless of vaccination status. The individual will be scheduled for the first available eye appointment. The individual is scheduled for 5/25/2023 with Geisinger Danville for dental anesthesia. 5/25/2023 was the first available appointment the dental provider had. |
05/30/2023
| Implemented |
| 6400.32(r) | At time of inspection there was no bedroom door lock on the bedroom door of Individual #9. Documentation that Individual #9 signed a statement stating they chose not to have a lock was completed on 1/9/23. There was no supporting documentation in the Individual Support Plan last updated on 1/13/23 to indicate that team discussion had occurred and that an informed choice had been made by the individual. | An individual has the right to lock the individual's bedroom door. | The individual¿s supports coordinator has been contacted to add the notation that the individual does not desire to have a locking mechanism on their bedroom door. The email request will be kept in the individual¿s file until ISP update has occurred.
(Attachment: ISP Update Request) |
04/26/2023
| Implemented |
| 6400.165(c) | Individual #2 is prescribed "Miralax powder 238 polyethylene Glycol 3350 mix 17gm powder in 8oz liquid and take by mouth daily." Individual #1 Medication Administration Records (MAR) for March 2023 indicate that the medication was administered each day up to the inspection date of March 27, 2023. At time of inspection there were three bottles of Miralax powder 238 in the home. Each bottle was 238 grams or 8.3 ounces. Label on the bottles indicate that the bottles contained 14 daily doses. Two of the three bottles were sealed and not in use. The bottle in use at the time of inspection was marked as being opened on 1/20/23. If administered as prescribed the bottle of Miralax in use at the time of inspection would have finished on 2/2/23. The Miralax for Individual #1 has not been administered as prescribed.
At time of inspection there were two full tubes of Denta 5000 Plus toothpaste in use for Individual #2. One tube had a pharmacy fill date of 7/22/22 and the other 9/28/22. The 9/28/22 tube was marked as being opened on 1/15/23. Both pharmacy labels appeared to be in good condition without evidence of wear and were easily read. Pharmacy label directions indicate that "Brush peas sized amount onto teeth at bedtime." The toothpaste was discussed with Staff #1 who indicated that the medication was often refused, and that staff would continue attempts to have Individual #2 brush their teeth throughout the day, it was indicated that Individual #2 would eventually comply. The March 2023 Medication Administration Records for Individual #2 do not record any refusals of the medication or denote the medication being administered at any other time than bedtime as directed or 8pm as indicated by staff initials on the March 23 MAR.
Prescription medications shall be administered as prescribed. | A prescription medication shall be administered as prescribed. | Training on medication prescription has been completed with the program to review medication prescription and staff responsibilities.
(Attachment: Bloss staff training) |
05/30/2023
| Implemented |