The Pines Residential Treatment Center 11/09 Inspection

DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES
CORRECTIVE ACTION PLAN Page: 1 of 71

Investigation ID:
License #: 909-14-003 Date of Inspection: 11-03-2009
Organization Name: The Pines Residential Treatment Center-ABS Program Type/Facility Name: Crawford Campus-The Pines
Standard(s) Cited Comp Description of Noncompliance Actions to be Taken Planned Comp. Date
1020.A - Any serious NS For I15 - On 11/3/09, OL Specialist was interviewing The facility ensures that any serious incident is reported 02/12/2010
incident reported w/in residents on the Compass Unit when resident I15 described within 24 hours to the placing agency, regulatory agencies
24 hours to placing an incident that occurred on 10/30/09. Provider failed to and the parent/guardian and noted on the incident report.
agency and guardian report serious incident involving resident, I15, within
24hours. On October 30, 2009, resident indicated to staff The facility ensures that all required and requested
that he did not want to live, turned down the hall and ran incidents are completed thoroughly with all required
head first into the exit door. Video confirmed the incident elements and reported to the licensure department on a
and showed that the resident was unconscious for Serious Incident Report (SIR), per Interdepartmental
approximately 1 minute, 55 seconds. Video also showed regulations and per conversations with Licensure. The
that staff failed to ensure resident's health & safety but not facility currently reports accidents or injuries requiring
attending to him, and when nurse arrived on the unit she did medical attention, elopements, allegations of abuse/neglect,
not assess the resident. Physician was not notified of the serious infractions of facility rules, suspected drug abuse,
incident and medical attention was not sought. Video also accusations of criminal conduct, serious illnesses, serious
showed that after staff escorted resident to his bedroom altercations with staff or peer, any self-harm or threat of
that the nurse was seen at the door way and did not assess self-harm, contraband found, suicidal gestures, and any
the resident. events causing impact on rights / responsibilities of legal
guardian.
For I16 - Provider failed to submit a serious incident report
within 24hrs. On 10/19/09 the Medication Error Information The facility ensures that significant medication errors are
Report indicates "Wrote a order on wrong resident - also reported on an SIR within 24 hours.
Resident had received one Ferrous Sulfate 325mg. No
allergic reaction - No known Drug allergies - No side effect." All incident reports are reviewed in morning meeting by the
Report prepared on 10/21/09. Risk Manager, or designee. The morning meeting involves
all campus disciplines and all incidents from the previous
I18 - Medication Error Information Report, dated 10/28/09, day are discussed to ensure that all incidents were captured
indicates "Doctor order placed in wrong chart, order on an incident report. It is through these incident reports
transcribed on Kardex - resident given one dose, no that the Risk Manager compiles the SIR for Licensure.
adverse side effect from medication."
The campus Risk Manager reviews daily and audits
I19 - Provider failed to report serious incident within 24 monthly all incident reports for 24 hour notification of all
hours. Medication Error Information Report, dated 9/26/09, parties. The audit reported monthly in PI Council.
indicates " Resident was given another residents meds in
error on the unit." Review of the documentation indicates After sending off the SIR, the facility follows up with an
that there is no nursing notes indicating the error; provider email to DBHDS with an account of all faxed reports for that
failed to notify a Physician of the error and the MAR day. The campus Administrator, Director of Performance
indicates that the resident received her medication as well. Improvement, and the CEO receive this information daily for
tracking purposes.
I22 - Provider failed to report serious incident within 24
hours. Risk Management - Incident Reporting form dated, PARTIALLY ACCEPTED:
10/24/09, "Medication not Tran scripted from CHKD PROVIDER NEEDS TO DEVELOP PROCEDURES FOR
Discharged Instruction - Zofran 8mg + Bactroban." THE SAFE GUARDING OF VIDEO FOOTAGE RELATING
Medication Error Information Report dated 10/24/09 TO SERIOUS INCIDENTS UNTIL ALL INVESTIGATIONS
indicated "Medication not Tran scripted from Discharged HAVE BEEN COMPLETED.
Instruction Medication list. One LPN says the medication
was placed on the MAR and one LPN says it was not; The facility ensures that video footage is safeguarded as it
medication was Coumadin. relates to serious incidents. The Risk Manager is
Investigation ID:
responsible for saving this footage as soon as he/she is

aware of the incident. The facility ensures these
requirements are in the Closed Circuit Cameras and
Recording System Policy.
ACCEPTED
1020.B.1 - Serious NS Same as 1020.A The facility ensures that any serious incident is reported 02/12/2010
incident: date and time within 24 hours to the placing agency, regulatory agencies
of incident and the parent/guardian and noted on the incident report.
The facility ensures that all required and requested

incidents are completed thoroughly with all required
elements and reported to the licensure department on a
Serious Incident Report (SIR), per Interdepartmental
regulations and per conversations with Licensure. The
facility currently reports accidents or injuries requiring
medical attention, elopements, allegations of abuse/neglect,
serious infractions of facility rules, suspected drug abuse,
accusations of criminal conduct, serious illnesses, serious
altercations with staff or peer, any self-harm or threat of
self-harm, contraband found, suicidal gestures, and any
events causing impact on rights / responsibilities of legal
guardian.
The facility ensures that significant medication errors are

also reported on an SIR within 24 hours.
All incident reports are reviewed in morning meeting by the

Risk Manager, or designee. The morning meeting involves
day are discussed to ensure that all incidents were captured
on an incident report. It is through these incident reports
that the Risk Manager compiles the SIR for Licensure.

monthly all incident reports for 24 hour notification of all
parties. The audit reported monthly in PI Council.
After sending off the SIR, the facility follows up with an

email to DBHDS with an account of all faxed reports for that
day. The campus Administrator, Director of Performance
Improvement, and the CEO receive this information daily for
tracking purposes.
PARTIALLY ACCEPTED:
PROVIDER NEEDS TO DEVELOP PROCEDURES FOR
Investigation ID:
THE SAFE GUARDING OF VIDEO FOOTAGE RELATING

TO SERIOUS INCIDENTS UNTIL ALL INVESTIGATIONS
HAVE BEEN COMPLETED.
The facility ensures that video footage is safeguarded as it

relates to serious incidents. The Risk Manager is
ACCEPTED
incident report- brief within 24 hours to the placing agency, regulatory agencies
description and the parent/guardian and noted on the incident report.

guardian.




Investigation ID:

tracking purposes.
PARTIALLY ACCEPTED:

ACCEPTED
incident report-action within 24 hours to the placing agency, regulatory agencies
taken and the parent/guardian and noted on the incident report.

guardian.



Investigation ID:

tracking purposes.
PARTIALLY ACCEPTED:

ACCEPTED
incident report-person within 24 hours to the placing agency, regulatory agencies
who completed report and the parent/guardian and noted on the incident report.

guardian.


Investigation ID:



tracking purposes.
PARTIALLY ACCEPTED:

ACCEPTED
who made report to and the parent/guardian and noted on the incident report.
parent
guardian.

Investigation ID:



tracking purposes.
PARTIALLY ACCEPTED:

ACCEPTED
to whom report was and the parent/guardian and noted on the incident report.
made
Investigation ID:

guardian.




tracking purposes.
PARTIALLY ACCEPTED:

ACCEPTED
1020.C - Report NS Same as 1020.A The facility ensures that any serious incident is reported 02/12/2010
serious illness or injury within 24 hours to the placing agency, regulatory agencies
w/in 24 hours to and the parent/guardian and noted on the incident report.
regulator
Investigation ID:

guardian.




tracking purposes.
PARTIALLY ACCEPTED:

ACCEPTED
1020.C.1 - Serious NS Same as 1020.A The facility ensures that any serious incident is reported 02/12/2010
incident report-date within 24 hours to the placing agency, regulatory agencies
and time of incident and the parent/guardian and noted on the incident report.

Investigation ID:

guardian.




tracking purposes.
PARTIALLY ACCEPTED:

ACCEPTED
Investigation ID:
incident report-brief within 24 hours to the placing agency, regulatory agencies
description and the parent/guardian and noted on the incident report.

guardian.




tracking purposes.
PARTIALLY ACCEPTED:

Investigation ID:

ACCEPTED
incident report-action within 24 hours to the placing agency, regulatory agencies
taken and the parent/guardian and noted on the incident report.

guardian.




tracking purposes.
PARTIALLY ACCEPTED:
Investigation ID:


ACCEPTED
incident report-name of within 24 hours to the placing agency, regulatory agencies
person who completed and the parent/guardian and noted on the incident report.
report
guardian.




Investigation ID:
tracking purposes.
PARTIALLY ACCEPTED:

ACCEPTED
person who made and the parent/guardian and noted on the incident report.
report to placing
agency and parent The facility ensures that all required and requested
guardian.



Investigation ID:

tracking purposes.
PARTIALLY ACCEPTED:

ACCEPTED
person to whom report and the parent/guardian and noted on the incident report.
was made
guardian.


Investigation ID:


tracking purposes.
PARTIALLY ACCEPTED:

ACCEPTED
1050.G - Posted routes N The McCall and BSP did not have posted routes of egress The facility ensures that all units have egress signs posted. 11/04/2009
of egress at the time of OL Specialists inspection of the unit. The Safety Officer and Risk Manager complete monthly
walk throughs and this item has been added to the walk
through list. The information from their walk throughs is
reported monthly in PI Council and in Environment of Care.
Updates are also expected monthly at PI Council to ensure
follow through from previous findings.
The McCall unit posted the sign on the day the error was
noted. The BSP unit had all postings removed due to the
unit being under construction and closed to staff and
residents. The Licensure staff was toured through that
space to show progress of renovations. All units under
construction will now post emergency exit signs.
ACCEPTED
300.B.5 - Annual N For S1 - Provider failed to complete an Annual Performance The facility ensures that all staff receives annual 01/30/2010
performance evaluation; evaluation was due 10/6/09. evaluations in a timely manner. The facility implemented a
evaluations new procedure to ensure timely evaluations. All
evaluations for all departments will be conducted in
December/January every year.
Investigation ID:
The facility Human Resources sent out Position

Descriptions (evaluation forms) for all positions to all
applicable department heads for review/revision for the
upcoming year. This occurred 12/11/09.
The facility department heads sent updated Job

Descriptions (JD) for all positions to Human Resources
compiled these JDs and placed on a public drive with all
other necessary evaluation material. This was completed
12/11/09.
Human Resources has now made available to each

supervisor, a list of their employees and the evaluations for
those employees. The evaluations are due back to Human
Resources by January 8, 2010.
The Director of Human Resources and Campus

Administrator will follow up with supervisors regarding any
late evaluations and delinquencies will be reported in PI
Council.
ACCEPTED
300.B.9 - N For S1 - Employee failed to properly fill out training forms The facility ensures that all training forms and tests 12/02/2009
Documentation of for the majority of all trainings provided ( Human Rights, completed during annual trainings are scored accurately.
required training and HIPPA Competency Test; Suicide Assessment Test; Packets of tests are created annually for all staff to
other training Customer Service; Cultural Diversity; Population Specific). complete, which includes all required competencies in one
Trainings were scored 100%. Perception whether or not handout. Each individual test is scored and the scores are
staff actually completed trainings. placed on a cover sheet, per test topic. The facility ensures
that each specific test has a score on the test and on the
cover sheet.
The facility ensures that Human Resources conduct random

personnel chart audits monthly. HR completes10% per
month and reports their findings to PI Council monthly.
ACCEPTED
310.B.1 - Annual N For S1 - Provider failed to maintain emergency The facility ensures that all training forms and tests 12/02/2009
refresher on preparedness and response training, annual date was completed during annual trainings are scored accurately.
emergency 10/6/09. Packets of tests are created annually for all staff to
preparedness complete, which includes all required competencies in one
handout. Each individual test is scored and the scores are
placed on a cover sheet, per test topic. The facility ensures
that each specific test has a score on the test and on the
cover sheet.

Investigation ID:
ACCEPTED
310.B.1a - Alerting N Same as 310.B.1 The facility ensures that all required competencies are 12/02/2009
emergency personnel, reviewed annually for all staff, including emergency
sounding alarms preparedness and alerting emergency personnel and
sounding alarms training. The facility ensures this is
included in the annual training fair required for all
employees and in new employee orientation.

ACCEPTED
310.B.1b - N Same as 310.B.1 The facility ensures that all required competencies are 12/02/2009
Implementing reviewed annually for all staff, including emergency
evacuation procedures preparedness and alerting emergency personnel and

ACCEPTED
310.B.1c - Using, N Same as 310.B.1 The facility ensures that all required competencies are 12/02/2009
maintaining emergency reviewed annually for all staff, including emergency
equipment. preparedness and alerting emergency personnel and

ACCEPTED
310.B.1d - Accessing N Same as 310.B.1 The facility ensures that all required competencies are 12/02/2009
emergency information reviewed annually for all staff, including emergency
preparedness and alerting emergency personnel and

Investigation ID:
ACCEPTED
310.B.1e - Utilizing N Same as 310.B.1 The facility ensures that all required competencies are 12/02/2009
community support reviewed annually for all staff, including emergency
services preparedness and alerting emergency personnel and

ACCEPTED
310.B.3 - Annual N For S1 - Provider failed to maintain behavior management The facility requires all direct care staff to be authorized and 12/02/2009
retraining child care training, expired 10/10/09. trained in behavioral techniques, before eligible to work.
staff in behavior Staff is also required to receive training on behavioral
intervention techniques annually.
All staff are trained in CPI Nonviolent Crisis Intervention

techniques during new employee orientation with an annual
refresher at each year of employment.
Human Resources reviews personnel files each month to

ensure training compliance. Any staff member who
experiences a lapse in CPI training is subject to suspension
pending training renewal. This information is reported
monthly in PI Council, by the Human Resources Manager.
ACCEPTED
310.E - N Personnel records reviewed did not contain evidence of The facility ensures Residential Counselors are properly 12/02/2009
Comprehensive staff training on how to run "psycho-educational groups." trained with in the facilitation of daily groups. Staff are
training based on trained by Unit Managers and Shift Supervisors and are
population needs provided with a packet of information to help guide them
with the process.
The facility ensures that each unit provides three groups per
day, which includes but is not limited to, morning wake up
group and evening wrap up group. The facility ensures that
staff signs a training sheet for these trainings to be placed
in their personnel file.

ACCEPTED
360.A.1 - Case N Provider failed to adequately coordinate case management The facility ensures that case management services are 12/02/2009
manager coordinates services. provided to all residents by the Case Managers and the
services Therapists. Notes from these types of services are often
Investigation ID:
times documented on Family Therapy notes since these

sessions include case management discussions.
The facility ensures that case management notes are

documented on a form titled “Case Management”.
Therapists and Case Managers are required to document
these notes for each resident weekly to capture discussions
regarding future placement, updates to sending agencies,
etc.
The facility ensures the ISP is updated to include these

requirements in the template.
The Director of Clinical Services reviews ISP‟s for current,

accurate and thorough information. 25% of resident ISP‟s
are reviewed monthly for 100% in 4 months. Results are
reported monthly in PI Council
ACCEPTED
440.C - Lighting N Compass A: The facility ensures that lighting is adequate and all burned 12/02/2009
adequate at night Room 858 - Bathroom light fixture needs to be replaced. out light bulbs are replaced as soon as possible. Staff who
find burned out lights are expected to complete a work
order form to have the light replaced as soon as possible.
Light in areas with no other lighting will be replaced
immediately.
Safety Officer, or designee will check for this during daily

building walk throughs. This information is reported in the
daily morning meeting with all department heads.
The Safety Officer and Risk Manager complete monthly

walk throughs and unit lighting has been added to the walk
through list. The information from their walk throughs is
reported monthly in PI Council and in Environment of Care.
Updates are reported monthly at PI Council to ensure follow
through from previous findings.
ACCEPTED
440.D - Operational N Several flashlights on the unit did not have batteries in The facility ensures that all units have operational 12/02/2009
flashlights or battery them. flashlights and/or powered lanterns. The Safety Officer and
powered lanterns Risk Manager complete monthly walk throughs and working
flashlights have been added to the walk through list. This
information is now reported monthly at PI Council. Updates
are reported monthly at PI Council to ensure follow through.
The facility ensures the campus is equipped with

Investigation ID:
emergency lighting on the units and in the hallways. Unit

staff has access to battery powered lanterns to use in a
case of emergency, which are kept in a secured area off the
units. The facility also ensures that batteries for flashlights
are kept in stock and the Unit Managers are required to
check for working flashlights monthly.
ACCEPTED
450.A - Plumbing in N Compass A: The facility ensures that plumbing is in good operational 06/30/2010
good operational Room 818: Moldy and Shower leaking. order for residents. As leaks are noted, staff document on a
condition work order, which is submitted to the maintenance
McCall Shower room light is not working. department for immediate repair.
The facility ensures bathrooms are cleaned daily by

housekeeping staff to include basic cleaning, replacing
shower curtains as needed, and reporting any light outage
on a maintenance request form.
Four units in the last year have gone through renovations,

which has included new bathrooms and reinforced ceilings.
Compass and McCall units are the only remaining units in
need of renovations. The facility is decades old and the
bathrooms contain stains and cracks that can no longer be
repaired. The facility will ensure the completion of the
renovation project in 2010, which will include renovated
bathrooms for McCall and Compass.
PARTIALLY ACCEPTED: Response does not indicate that

items cited have been addressed. Also, the projected
completed date of proposed renovations needs to be
indicated.
The facility will ensure the completion of renovation projects

on the McCall and Compass bathrooms. A CER was
submitted to our corporate office on 2/8/10 for approval.
Once approved, the renovation projects will begin. Each
bathroom should take approximately 2 weeks. Estimated
completion of entire project is June 30, 2010.
ACCEPTED
480.F - Clean bed and N Compass A: The facility ensures residents are provided with clean linen 12/02/2009
linens Room 858 - No pillow cases and no blankets. and towels. Each unit has a locked area stocked with an
adequate supply of linen for residents to access as needed.
As bed linen is in need of replenishment, the old linen is
removed and taken by housekeeping staff. Housekeeping
will add linen checks to their room checklist and this
information will be monitored by the house keeping
supervisor.
Investigation ID:
ACCEPTED
490 - Smoking is N Resident found three times smoking cigarettes. The facility ensures that smoking is prohibited in living 12/02/2009
prohibited in living areas of the building. Residents with a history of smoking
areas, where children are referred to their therapist and physician to discuss
participate smoking cessation issues. The facility ensures that rooms
are randomly searched daily for contraband. As contraband
is found, it is given to the shift supervisor or unit manager
and reported on an incident report. This information goes to
the campus Risk Manager for reporting.
Residents are discouraged from hiding contraband for their

peers and are encouraged to hand over this contraband to
staff. When contraband items are found, staff and residents
participate in a daily group session to discuss. These are
documented for each resident on a daily group note and
placed in the resident‟s chart.
The facility has made changes since these incidents to help

deter contraband from entering the facility. Our variance
with Licensure for resident strip searches was renewed and
these searches are conducted when residents return to the
facility from a pass.
Staff access to the building was changed to provide only

one entryway through the front door. Staff is not to bring in
bags of items and is encouraged to leave all personal items
at home.
Contraband items are reported to Risk Manager who will

report monthly in Safety Committee.
ACCEPTED
540 - Laundry N The washer on Compass B in disrepair, washer lid not The facility will ensure each unit has working washing 12/02/2009
equipment in good secure and rusted. machines and dryers in good working order. Machines are
repair reviewed every month by the Safety Officer and new
machines are ordered approximately every six months. The
Safety Officer reports conditions of the machines in the
monthly Environment of Care meeting. Request for the
purchase of new machines is sent to the CFO and CEO for
approval. Due to the high use of the machines, they are
replaced often and become worn quickly.
A Purchase Order was completed on 11/4/09 for new

machines to replace the broken machines on Compass B.
New machines should arrive by February 2010.
ACCEPTED
570 - Space for N Environmental review of units resulted in a number of The facility ensures that a space is provided for 12/02/2009
Investigation ID:
administrative activities individual documentation in unsecured areas (boxes, administrative activities and confidential conversations.
and confidential nonlocked file cabinets, shelves). During renovations, the facility will ensure that items and
conversations documents are packed and/or filed in appropriate places
and secure behind locked doors in an orderly manner. The
items were removed and placed in a secure manner on
11/4/09.
ACCEPTED
580.A - Safe, properly N Courtyard off the Compass unit had debris and leaves. The facility ensures buildings are safe, maintained, and in 12/02/2009
maintained grounds clean working order. A review of door hinges has been
free from rubbish completed and many of the old hinges need to be replaced.
These issues of loose screws were discussed in the

monthly Environment of Care meeting on 11/19/09. Risk
Manager reports all incidents with screws and/or destruction
to property to the Safety Officer every morning in morning
meeting. The Safety Officer follows up with the
maintenance staff and issues are fixed daily to reduce the
opportunity of residents from harming self with screws
and/or damaged property.
ACCEPTED
580.B - Buildings safe, N BSP Unit: The facility ensures buildings are safe, maintained, and in 12/02/2009
maintained, clean, Room 716 - Door mechanism screws were loose and could clean working order. A review of door hinges has been
working order lead to health & safety issue considering the resident who completed and many of the old hinges need to be replaced.
resides in the room.
These issues of loose screws were discussed in the
monthly Environment of Care meeting on 11/19/09. Risk
Manager reports all incidents with screws and/or destruction
to property to the Safety Officer every morning in morning
meeting. The Safety Officer follows up with the
maintenance staff and issues are fixed daily to reduce the
opportunity of residents from harming self with screws
and/or damaged property.
ACCEPTED
600.A - Bldgs well- N Several boys‟ rooms had offensive odors and needed to be The facility ensures the buildings are well ventilated and 12/02/2009
ventilated and free of cleaned. free of foul odors. Bedrooms were clean, but had dirty
foul odors clothing in basket which caused room to smell stale. The
Unit Managers will ensure residents wash clothing on
scheduled day. Staff will support residents with washing
clothing on non wash days when clothing smells dirty.

walk throughs and room cleanliness has been added to the
walk through list. The information from their walk throughs
is reported monthly in PI Council and in Environment of
Investigation ID:
Care. Updates are also expected monthly at PI Council to

ensure follow through from previous findings
ACCEPTED
650.A - Approval of N For I12 - Provider failed to place individual prior to getting The facility ensures residents who are under 18 and from 12/02/2009
Interstate Compact approval from ICPC. Interstate Placement Transmittal, out of Virginia, have received approval from Interstate
dated 3/6/09 indicates "We understand this D.C. child was Compact for placement. Admissions staff is required to
place into The Pines on12/21/08, without ICPC approval. apply to ICPC for placement and admissions committee will
not accept a resident without proper approval.
Admissions staff will complete a monthly audit of all new

admissions to ensure ICPC documents are in resident
charts. The audit results will be reported monthly to PI
Council.
ACCEPTED
650.E - Out-of-state N For I12 - Provider failed to place individual prior to getting The facility ensures residents who are under 18 and from 12/02/2009
approval by Interstate approval from ICPC. Interstate Placement Transmittal, out of Virginia, have received approval from Interstate
Compact dated 3/6/09 indicates "We understand this D.C. child was Compact for placement. Admissions staff is required to
place into The Pines on12/21/08, without ICPC approval. apply to ICPC for placement and admissions committee will
not accept a resident without proper approval.
Admissions staff will complete a monthly audit of all new

admissions to ensure ICPC documents are in resident
charts. The audit results will be reported monthly to PI
Council.
ACCEPTED
680.D.2 - Staff trained N Staff is responsible to provide "psycho-educational groups" The facility ensure that staff is properly trained to meet the 12/02/2009
to meet resident needs but there was no documentation that staff has had any needs of the residents served.
formal training providing instructional as to how to run and
assess these groups. The facility ensures Residential Counselors are properly
trained with in the facilitation of daily groups. Staff is trained
by Unit Managers and Shift Supervisors and is provided
with a packet of information to help guide them with the
process.

ACCEPTED
70.E - License Posted N DBHDS License not prominently posted. The facility ensures that the current license is posted in the 11/09/2009
Investigation ID:
lobby at all times. The license is currently posted, but has

expired. The facility has requested a new license or letter
of good standing.
ACCEPTED
70.I - Comply with N Human Rights issues. (related to the handling of incident The facility complies with all applicable rules, regulations, 12/02/2009
applicable fed., state, cited, revised 12/4/09). and laws from all oversight bodies. The facility ensures the
local laws and regs completion of the Human Rights Notification forms within 24
hours for all physical altercations with contact, elopements
from the facility and/or outing, allegations against staff, and
sexual misconduct of any kind, per regulations.
After sending Human Rights Notification form, the facility

follows up with an email to DBHDS with an account of all
faxed reports for that day. The campus Administrator,
Director of Performance Improvement, and the CEO receive
this information daily for tracking purposes. Then during the
daily morning meetings with the executive team, the PI
Director discusses the reports sent the prior day.
ACCEPTED
70.K - Comply with NS Several P&P reviewed indicated that the provider is not The facility ensures compliance with own policies and 12/30/2009
own policies and complying with its own P&P (Medication Administration, procedures. All polices discussed during annual review are
procedures Pxyis, Client Funds, ICPC, and reporting incidents). in the process of revision to ensure compliance. Polices
are revised by appropriate department staff then sent to
policy and procedure committee for approval. Once
committee approves, policies are presented to the
Executive Professional Staff for final approval. New policies
are then distributed.
ACCEPTED
710 - Initial objectives NS REPEAT VIOLATION: The facility ensures all residents have initial objectives and 12/02/2009
and strategies- 3 days Provider failed to follow plan of correction of 10/28/08 which strategies on their initial treatment plan at admission
indicated "Objectives and intervention strategies documented within 3 days of admission before their
traditionally have been delineated in the admitting comprehensive plan is developed. This initial treatment
psychiatrist‟s admission note. The facility developed a new plan is developed and shared with the resident, the
form to address goals and objectives and form is filed under guardian and with all staff who work with that resident. The
treatment plan section of chart." facility revised the Initial Treatment Plan format to include
strategies and began using the new format on 10/12/09.
For I12 - Initial treatment plan, dated 12/26/08 but individual
admitted as of 12/21/08 per ICPC. There are no strategies Psychiatrists were trained on documentation of objectives
indicated in the initial treatment plan. and strategies in October 2009 and are using the new
format for all new admissions.
For I16 - Initial treatment plan, dated March 31, 2009,
objectives indicated did not have strategies. Audits are performed monthly by several departments to
review the use of all approved documents. Results from
For I20 - Initial treatment plan dated 8/18/09 did not address these audits are reported in PI Council monthly for tracking
the resident's pregnancy purposes.
Investigation ID:
ACCEPTED
For I21 - Initial treatment plan dated 10/7/09 did not have
any strategies.
720.A - ISP within 30 N For I26 - Resident is a High School graduate that has The facility ensures the completion of an ISP every 30 days 12/07/2009
days participated in several classes since being admitted but and includes educational updates. In June 2009, the facility
request by father to enroll resident in online college classes ordered computers for resident use, internet access, and
has not been resolved. programming to allow residents to complete on line
courses. The course work could not begin until all items
arrived and were set up for resident use.
The resident first logged into classes on 12/7/09. The

classes are self paced and she receives assistance from
the education staff.

reported monthly in PI Council.
ACCEPTED
720.B.2 - ISP N For I26 - Provider failed to properly assess or revise Mental The facility ensures that all ISP‟s completed includes the 12/02/2009
describes current Status report. Mental Status on treatment plans dated resident‟s current functioning. The Director of Clinical
functioning 9/29/09-10/28/09 and 10/29/09-11/27/09, are identical. Services reviews IPSs for accuracy and thoroughness. The
facility ensures the therapists receive monthly summaries
from the Psychiatrist in a timely manner to incorporate into
the monthly ISP. The Psychiatrists provide an updated
Mental Status for their caseload, as required.

ACCEPTED
720.C - ISP reviewed N For I12 - Provider failed to have a valid Individual Service The facility reviews all ISP‟s every 30 days. Therapists and 12/02/2009
w/in 60 days, 90 days Plan in the record. ISP in the record is stamped as "Draft", case workers have been trained on how to complete the
thereafter dated 11/2/09-12/1/09. ISP and all of the elements required in complete
documentation. All therapists and case workers were
trained in the new ISP process and format in July 2009.
They have been trained to have the ISP completed by the

expiration of the previous ISP and ISP‟s with “draft” are not
accepted in the chart. Meeting schedules have been
adjusted to allow completion of ISP and filing in the chart.
Investigation ID:

ACCEPTED
720.D - P&P's to N Cited the same as 720.C The facility ensures policies and procedures are in place for
document progress in documenting progress with meeting goals. Therapists and
meeting goals For I26 - Provider failed to accurately measure the Case Workers review progress on goals and objectives at
individual treatment progress goals and objectives of ISP least monthly and update the goals and objectives
for I26. accordingly.
The following information on the ISPs. Exact progress
notes, dates and information on two ISPs. for 8/12th, 13th, Therapists and case workers have been trained on how to
and 14th complete the ISP and all of the elements required in
complete documentation. All therapists and case workers
1. Progress Goals - from ISP for 8/14/09- 9/14/09 were trained in the new ISP process in July 2009
Individual Therapy- "Individual sessions were held on
August 12th, 13th, 14th by Jessica Maier. I26 has been The Director of Clinical Services reviews ISP‟s for current,
open with the therapist about the behaviors that put her in accurate and thorough information. 25% of resident ISP‟s
placement. She presents as very depressed, but motivated are reviewed monthly for 100% in 4 months. Results are
to change. So far I26 has been honest about drug use, reported monthly in PI Council.
abuse and cutting. She has had some dissociative
episodes during sessions that seem related to anxiety." ACCEPTED
Treatment Progress
1. Progress Goals- from 8/31/09- 9/30/09
Individual Therapy- "Individual sessions were held on
August 12th, 13th, 14th by Jessica Maier. I26 has been
open with the therapist about the behaviors that put her in
placement. She presents as very depressed, but motivated
to change. So far I26 has been honest about drug use,
abuse and cutting. She has had some dissociative
episodes during sessions that seem related to anxiety."
720.D.1 - ISP format N Cited the same as 720.D The facility ensures that the Therapists and Case Workers 12/02/2009
use the approved ISP format. Therapists and case workers
have been trained on how to complete the ISP and all of the
elements required in complete documentation. All therapists
and case workers were trained in the new ISP process in
July 2009.

Investigation ID:

ACCEPTED
720.D.2 - P&P's N Cited the same as 720.D The facility ensures polices and procedures are in place to 12/02/2009
address documentation address documentation frequency. Therapists and case
frequency workers have been trained on how to complete the ISP and
all of the elements required in complete documentation. All
therapists and case workers were trained in the new ISP
process in July 2009

ACCEPTED
720.D.3 - P&P's N Cited the same as 720.D The facility ensures policies and procedure are in place to 12/02/2009
address person indicate person responsible for documentation. Therapists
responsible for and case workers have been trained on how to complete
documentation the ISP and all of the elements required in complete
documentation. All therapists and case workers were
trained in the new ISP process in July 2009

ACCEPTED
720.E - Quarterly N Cited the same as 720.D The facility ensures status of discharge planning is 12/02/2009
addresses status of addressed quarterly in the ISP. Therapists and case
discharge planning workers have been trained on how to complete the ISP and

ACCEPTED
720.E.1 - Quarterly N Cited the same as 720.D The facility ensures resident progress is reviewed quarterly 12/02/2009
shall review resident in the ISP and with the resident. Therapists and case
progress workers have been trained on how to complete the ISP and
Investigation ID:

ACCEPTED
720.E.2 - Quarterly N Cited the same as 720.D The facility ensures that family involvement is offered and 12/02/2009
address family occurs regularly and is documented in the ISP quarterly.
involvement
Visitation and attendance at staffing, whether in person or
over the phone, is documented in the progress note and on
the updated treatment plan which is signed by all
participants and mailed out immediately after the staffings
and or family sessions, by the Treatment Planner.
In October 2009, all Therapists and case workers were

educated on the importance of family involvement and the
requirement of family therapy twice per month.
The facility now ensures documentation of date, time,

location and duration and participants of visits for meetings,
family therapy sessions, staffings, informal visits, etc. in the
resident‟s record in the progress section.

ACCEPTED
720.E.3 - Quarterly N Cited the same as 720.D The facility ensures that continuing needs are addressed in 12/02/2009
address continuing the ISP quarterly. Therapists and case workers have been
needs trained on how to complete the ISP and all of the elements
required in complete documentation. All therapists and case
workers were trained in the new ISP process in July 2009

ACCEPTED
720.E.4 - Quarterly N Cited the same as 720.D The facility now ensures that each resident‟s progress 12/02/2009
address progress toward discharge is documented quarterly as a part of the
toward discharge ISP.
Investigation ID:
The facility ensures that the Clinical Care Coordinator or

designee attends weekly treatment team meetings to
ensure proper communication regarding client progress
toward discharge and now ensures this information is a part
of the ISP each month.
The Director of Clinical Care Coordination has created a

contact list of people to notify before and after a client is
discharged. The Clinical Care Coordination / UR
department is responsible for ensure this communication
occurs and the Therapist / Case Manager documents it in
the ISP.
In July 2009, a Discharge Management Case Note was

created to provide more detail to assist with discharge.
Staff has been trained on discharge documentation and all
elements required for complete and thorough
documentation of client progress. Staff training has been
documented and placed in staff HR files.
The Director of Clinical Care Coordination will audit 25% of

the resident charts ISPs monthly so that 100% are
completed every 4 months to ensure that progress toward
discharge is documented. This will be reported monthly in
PI Council.
ACCEPTED
720.E.5 - Quarterly N Cited the same as 720.D The facility now ensures that each resident‟s progress 12/02/2009
reviews status of toward discharge is documented quarterly as a part of the
discharge planning ISP.
The facility ensures that the Clinical Care Coordinator or

designee attends weekly treatment team meetings to
ensure proper communication regarding client progress
toward discharge and now ensures this information is a part
of the ISP each month.
The Director of Clinical Care Coordination has created a

contact list of people to notify before and after a client is
discharged. The Clinical Care Coordination / UR
department is responsible for ensure this communication
occurs and the Therapist / Case Manager documents it in
the ISP.
In July 2009, a Discharge Management Case Note was

created to provide more detail to assist with discharge.
Investigation ID:
Staff has been trained on discharge documentation and all

elements required for complete and thorough
documentation of client progress. Staff training has been
documented and placed in staff HR files.
The Director of Clinical Care Coordination will audit 25% of

the resident charts ISPs monthly so that 100% are
completed every 4 months to ensure that progress toward
discharge is documented. This will be reported monthly in
PI Council.
ACCEPTED
720.F - Plan and N Cited the same as 720.D The facility ensures that the ISP includes dates and 12/02/2009
quarterlies have date signatures. Therapists and case workers have been trained
and signature on how to complete the ISP and all of the elements required
in complete documentation. All therapists and case workers
were trained in the new ISP process in July 2009

ACCEPTED
720.G - Staff daily N For I12 and I21, there was no documentation to support that The facility ensures that daily documentation describes the
implementing ISP staff provide groups, "psycho-educational groups" and that resident‟s behavior and links to the ISP. The facility
describes resident's staff will "provide clear expectations for behaviors and ensures Residential Counselors are properly trained with in
behavior immediately and immediately hold him accountable for not the facilitation of daily groups. Staff is trained by Unit
following directives and rules.", in the record. Managers and Shift Supervisors and is provided with a
packet of information to help guide them with the process.
Progress notes reviewed do not adequate address the
outcomes indicated in the treatment plan. The facility ensures that each unit provides three groups per
The facility ensures the Human Resources conduct s

random personnel chart audits monthly. They will complete
10% per month and report their findings to PI Council
monthly.
ACCEPTED
720.I - ISPs, N The treatment plans reviewed do not indicate why the plan The facility ensures that ISP‟s and other necessary 12/02/2009
Quarterlies distributed was not distributed to the individual. documentation are distributed timely to resident,
to resident, family, family/guardian, placing agency and other needed contacts.
legal guardian, placing
agency The facility ensures that each resident‟s therapist reviews
Investigation ID:
the dates of the ISP meetings and the results of the ISP
meeting with the resident. These conversations are
documented on the individual therapy notes. A section has
been added to the ISP to indicate the confidentiality issues
that prevent Therapists from giving the resident a copy of
the ISP.
Therapists and case workers document in daily progress

notes to whom and when appropriate documents have been
given/sent to resident , family/guardian, placing agency and
other needed contacts.
The Clinical Director reviews and audits these notes with

therapist during weekly supervision. The results of the audit
are reported monthly in PI Council.
ACCEPTED
760.A - Program N For I12 - Documentation reviewed does not indicate that The facility ensures that case management services are 12/02/2009
provides case "Case Management" has been provided. provided to all residents by the Case Managers and the
management services Therapists. Notes from these types of services are often
For I20 - Documentation reviewed does not indicate that times documented on Family Therapy notes since these
"Case Management" has been provided. sessions include case management discussions.

etc.
The facility also ensures the ISP template includes these

requirements. The Director of Clinical Services monitors
the templates during monthly audits.
ACCEPTED
760.A.1 - Helping N Cited the same as 760.A The facility ensures the Therapists and Case Managers 12/02/2009
resident understand help the resident understand the effects of separation and
effects of separation & group living.
group living
The facility ensures that case management services are
provided to all residents by the Case Managers and the
Therapists. Notes from these types of services are often

Investigation ID:

etc.


ACCEPTED
760.A.2 - Assisting in N Cited the same as 760.A The facility ensures the Therapists and Case Managers 12/02/2009
maintaining family assist the resident in maintaining family relationships.
relationships

etc.


ACCEPTED
760.A.3 - Utilizing N Cited the same as 760.A The facility ensures the Therapists and Case Managers 12/02/2009
community resources help residents utilize community resources.

Investigation ID:

etc.


ACCEPTED
760.A.4 - Strengthen N Cited the same as 760.A The facility ensures the Therapists and Case Managers 12/02/2009
relationships help residents strengthen relationships.


etc.


ACCEPTED
760.A.5 - Conferring N Cited the same as 760.A The facility ensures the Therapists and Case Managers
with staff re: resident's confer with staff regarding resident needs.
needs
Investigation ID:


etc.


ACCEPTED
760.A.6 - Working for N Cited the same as 760.A The facility ensures the Therapists and Case Managers 12/02/2009
resident's future work on the resident‟s future.


etc.


Investigation ID:
ACCEPTED
760.B - Provision of N Cited the same as 760.A The facility ensures that all required case management 12/02/2009
case management notes are filed in the chart as soon as they are completed.
services documented
in record The facility ensures that all case management notes, which
can be completed by the clinical care coordination
department, the therapist and any other staff person, are
placed in the resident‟s chart immediately upon completion.
All case management notes are placed in the progress
notes section of chart #2 and are titled, “Case Management
Note” at the top of the form. These notes can be used to
document conversations with placing agency, changes in
discharge planning, and a change in therapist.
The Director of Clinical Services reviews notes for current,

accurate and thorough descriptions of the case
management completed for that month. 25% of resident
charts are reviewed monthly for 100% in 4 months. Results
are reported monthly in PI Council.
ACCEPTED
780.A.1 - Structured N For I12 and I21- There was no documentation to support The facility now provides a structured program of care to 12/02/2009
program of care to that staff provided "psycho-educational groups" and that meet the physical and emotional needs of the residents.
meet physical and staff will "provide clear expectations for behaviors and The facility ensures Residential Counselors are properly
emotional needs immediately and immediately hold him accountable for not trained with in the facilitation of daily groups. Staff is trained
following directives and rules." by Unit Managers and Shift Supervisors and is provided
process.
The facility ensures Human Resources conduct random

personnel chart audits monthly. They will complete 10%
per month and report their findings to PI Council monthly.
ACCEPTED
780.A.2 - Structured N For I12 and I21- There was no documentation to support The facility now ensures that a structured program of care is 12/02/2009
program of care to that staff provided "psycho-educational groups" and that provided for the protection, guidance and supervision of all
provide protection, staff will "provide clear expectations for behaviors and residents. The facility ensures Residential Counselors are
guidance, and immediately and immediately hold him accountable for not properly trained with in the facilitation of daily groups. Staff
supervision following directives and rules." is trained by Unit Managers and Shift Supervisors and is
provided with a packet of information to help guide them
Investigation ID:
with the process.

ACCEPTED
780.A.3 - Structured N For I12 and I21- There was no documentation to support The facility will provide a structured program of care to meet 12/02/2009
program of care to that staff provided "psycho-educational groups" and that objectives of ISP. The facility will ensure Residential
meet objectives of ISP staff will "provide clear expectations for behaviors and Counselors are properly trained with in the facilitation of
immediately and immediately hold him accountable for not daily groups. Staff is trained by Unit Managers and Shift
following directives and rules." Supervisors and is provided with a packet of information to
help guide them with the process.
The facility ensures Human Resources Managers conduct

random personnel chart audits monthly. They will complete
10% per month and report their findings to PI Council
monthly.
ACCEPTED
780.B - Daily structured N For I12 and I21- There was no documentation to support The facility provides a daily structured routine for residents. 12/02/2009
routine that staff provided "psycho-educational groups" and that All program schedules were revised in July 2009 to allow for
staff will "provide clear expectations for behaviors and milieu management changes and have since been revised
immediately and immediately hold him accountable for not monthly to ensure structured routine.
following directives and rules."
The facility ensures Residential Counselors are properly
trained with in the facilitation of daily groups. Staff is trained
process.
Investigation ID:


ACCEPTED
780.C - Daily N For I12 and I21- There was no documentation to support The facility ensures a daily communication log is maintained 12/02/2009
communication log of that staff provided "psycho-educational groups" and that to document and communicate daily happenings.
significant happenings staff will "provide clear expectations for behaviors and
immediately and immediately hold him accountable for not The facility ensures Residential Counselors are properly
following directives and rules." trained with in the facilitation of daily groups. Staff is trained
process.

per month and report their findings to PI Council monthly
ACCEPTED
780.D - Health/dental N For I12 and I21- There was no documentation to support The facility ensures all health and dental complaints and 12/02/2009
complaints and injuries that staff provided "psycho-educational groups" and that injuries are recorded. Health and dental complaints and
recorded staff will "provide clear expectations for behaviors and injuries are reviewed in morning meeting and the resident is
immediately and immediately hold him accountable for not assessed as appropriate by nursing and/or physician and/or
following directives and rules." dentist. The facility ensures Residential Counselors are
properly trained with in the facilitation of daily groups. Staff
is trained by Unit Managers and Shift Supervisors and is
with the process.

Investigation ID:

ACCEPTED
780.E - Person making N For I12 and I21- There was no documentation to support The facility ensures the person who is making the entry in 12/02/2009
entries in log identified that staff provided "psycho-educational groups" and that the communication log is identified by positions and/or
staff will "provide clear expectations for behaviors and credentials. The facility ensures Residential Counselors are
immediately and immediately hold him accountable for not properly trained with in the facilitation of daily groups. Staff
following directives and rules." is trained by Unit Managers and Shift Supervisors and is
with the process.

ACCEPTED
780.F - Residents N For I12 and I21- There was no documentation to support The facility ensures residents receive sleep and rest. Bed 12/02/2009
receive sleep and rest that staff provided "psycho-educational groups" and that times are re-enforced by staff. Residents that have difficulty
staff will "provide clear expectations for behaviors and sleeping are discussed in morning meeting and referred to
immediately and immediately hold him accountable for not their physician for medication review as needed. The
following directives and rules." facility ensures Residential Counselors are properly trained
with in the facilitation of daily groups. Staff is trained by
Unit Managers and Shift Supervisors and is provided with a

Video monitoring is also conducted randomly by Risk
Manager to review compliance with curfew.
ACCEPTED
780.G - Promote and N For I12 and I21- There was no documentation to support The facility ensures that staff promote and support good 02/15/2010
support good hygiene that staff provided "psycho-educational groups" and that hygiene. The unit schedules include times for self care and
Investigation ID:
staff will "provide clear expectations for behaviors and hygiene. Residents that do not participate in hygiene time
immediately and immediately hold him accountable for not are discussed in morning meeting and referred to their
following directives and rules." therapist to discuss as needed. The facility ensures
Residential Counselors are properly trained with in the
facilitation of daily groups. Staff is trained by Unit Managers
and Shift Supervisors and is provided with a packet of
information to help guide them with the process.

PARTIALLY ACCEPTED: PROVIDER IS REQUIRED TO

INDICATE "PLANNED COMPLETION DATE"
12/4/10 Managers and Team Leaders trained
1/18/10 New employees trained
2/15/10 Large trainings for all direct care staff to begin
The facility began a new training for group facilitation on

December 4, 2009. Trainings continue for all direct care
staff at New Employee Orientation and at shift change
meetings. Staff has signed Attestations to document the
training
780.H - Comply with N For I12 and I21- There was no documentation to support The facility ensures residents comply with curfews. Bed 12/02/2009
curfews that staff provided "psycho-educational groups" and that times are re-enforced by staff. Residents that have difficulty
staff will "provide clear expectations for behaviors and sleeping are discussed in morning meeting and referred to
immediately and immediately hold him accountable for not their physician for medication review as needed. The
following directives and rules." facility ensures Residential Counselors are properly trained
with in the facilitation of daily groups. Staff is trained by
Unit Managers and Shift Supervisors and is provided with a
Investigation ID:

Video monitoring is also conducted randomly by Risk
Manager to review compliance with curfew.
ACCEPTED
810.C - Staff informed N Resident receives Advair but nurse questioned did not know The facility ensures that all medication side effects are 12/17/2009
of known med side that an individual should rinse mouth after using inhaler for properly identified. Pharmacy reviews any new medications
effects the prevention of side effect. and known side effects in Safety Committee and nursing
leadership trains staff in nursing staff meetings as new
information is received. Adverse reactions and side effects
are reported to the physician and resident will be evaluated
by nursing and/or physician for necessary medical
response. Incident reports are completed for adverse drug
reactions. Each medication prescribed by the pharmacy is
placed on the MAR, by resident, by month. The pharmacy
now includes a section on the MAR for special instructions
and side effects for that resident.
The Director of Nursing provides training to all nurses on

the use of Advair. This is documented on a signed
attestation by all nurses and placed in their personnel file.
ACCEPTED
810.D - Medications NS For I7 - Resident refused 8pm Trazodone for a number of The facility now ensures that all medications are 12/17/2009
must be prescribed days in October but there is no indication that the Dr. administered as prescribed. Nurses and therapists
responded to this issue. encourage medication compliance for all residents that
refuse their medications. Medication refusals are reported
For I6 - Medication Error Information Report dated 10/21/09 in morning meeting and referred to their physician as
indicates that on 10/19 (and 10/20) "Wrote a order on needed.
wrong resident - Resident had received one Ferrous Sulfate
325mg. No allergic reaction - No known drug allergies - no Audits are completed by the nursing staff prior to the end of
side effect." Transcribe order on wrong patient. Dated each shift to ensure proper completion of the Medication
10/21/09. MAR reviewed indicated three doses given and Administration Record (MAR). Audit results are submitted
progress notes reviewed do not indicate error or that Doctor daily to the Director of Nursing (DON) or their designee for
was notified. review. The DON reports the results of the audits to the
monthly PI Council.
Several Medication Error Information Reports, dated
10/3/2009 were reviewed which documented a failure by The facility ensures that all medication errors are
the Provider‟s program of medication used to monitor the documented on a Medication Error repot, prior to leaving
ordering and accounting for medications. On October 3, the shift. This information is also documented on an
2009, an RN documented that the Provider‟s Pixis internal incident report and forwarded to the Risk Manager
Computer had either wrong medications listed for resident for reporting.
or wrong dosages listed for residents. Even though the RN
Investigation ID:
documented these systems errors, there was no evidence The facility ensures that orders are correct on the MAR as
found that Provider researched the causes for these noted changes come from the M.D‟s. Audits are completed by the
discrepancies or took action to correct the errors. The nursing staff prior to the end of each shift to ensure orders
following are the errors or potential for errors documented: on the MAR are accurate. Audit results are submitted daily
to the Director of Nursing (DON) or their designee for
1. Resident I3 - Remeron 7.5 mg prescribed for resident review. The DON reports the results of the audits to the
does not show on Pixis items list. Prescription show up in monthly PI Council.
view orders. Resident needs drug loaded in pixis.
The job descriptions for nursing staff have been revised to
2. Resident I22 - 10/3/09;1600; Residents anticoagulant is include information on the requirements and expectations
inaccessible. The generic Warfarin shows on patients view for medication administrator at the facility.
orders as not loaded in this station, but the brand name
Jantovin is in inventory. Generic and Brand Name The facility ensures each nurse signs an attestation form
confusion with pixis. (supervision form) to acknowledge the importance in: Filling
out MAR‟s, using first dose stamp, follow up on back of
3. Resident I23 - Pixis has potential for damaging med MAR, completing pain assessment form, and completing
error. Resident has not been prescribed Lithium. Drug is incident forms / medication error forms. These forms are
listed on his profile as Lithium 300 Mg, Give one CAP by filed in each nurses‟ personnel file.
mouth at bedtime for impulse. ACCEPTED
4. Resident I15 - Pixis has potential for damaging med

error. Resident has not been prescribed the drug
Clonazepam. Drug is listed on his profile as Clonazepam
0.25 mg inject as directed by physician.
5. Resident I24 - Potential for overdose. Resident‟s

Seroquel was increased from 600 mg to 700 mg. The order
used to read “Seroquel 300mg – give 2 tabs at bedtime”.
Pharmacy added an order for “Seroquel 400 mg. Give 1
Tab at bedtime. Pixis still reads give 2 -300 mg tabs (plus
the new 400 mg =1000mg). Improper dose/quantity.
6. Resident 25 - Resident has been on Ducosate 100 mg

since her admission in 2008. Drug is inaccessible now. It
does not show on patient‟s item list. It does show on view
orders list but states, “ not loaded in this station”. Drug is in
inventory.
Specialist interviewed the staff responsible for maintaining

the system at the time of these noted discrepancies and
was informed that the discrepancies had not been
investigated as they thought the RN‟s documenting these
errors was unnecessary. Therefore, no action has been
taken to ensure resident‟s medication prescription profiles
and orders are documented correctly in Provider‟s
medication Program (Prixis). Potential for abuse.
Investigation ID:
810.E - Medications NS For I1 - The facility ensures that medications are administered as 12/17/2009
administered as Ibuprofen 400mg , give 1 tablet by mouth every 8 hours as prescribed. Nurses and therapists encourage medication
prescribed need for pain. On 10/18 & 10/22 medication given but MAR compliance for all residents that refuse their medications.
does not have reason for or results indicated. Medication refusals are reported in morning meeting and
Acetaminophen 325mg give 2 TABs by mouth every 4 referred to their physician as needed.
hours prn for H/A, body ache or Temp. On 10/14 & 10/29
medication given but MAR does not have reason for or Audits are completed by the nursing staff prior to the end of
results indicated. each shift to ensure proper completion of the Medication
Administration Record (MAR). Audit results are submitted
For I2 - daily to the Director of Nursing (DON) or their designee for
Ibuprofen 600mg 1 TAB by mouth every 6 hours as needed review. The DON reports the results of the audits to the
for pain was given on 10/10; 10/12; 10/27; 10/29 @0215; monthly PI Council.
10/29 @ 3:40pm; and 10/29 @ 11:50; 10/20 @ 3:10pm;
10/30 @ 9:30pm; 10/31 @ 5:30pm and 10/31 @ 0400 but The facility ensures that all medication errors are
no indication as to why or if resolved. documented on a Medication Error repot, prior to leaving
the shift. This information is also documented on an
For I3 - internal incident report and forwarded to the Risk Manager
Abilify 2.5mg 8pm medication not signed or reason on for reporting.
10/10.
Terbinafine 1% cream apply to ringworm on chest at The facility ensures that orders are correct on the MAR as
bedtime til resolved or max of 4 weeks. The majority of the changes come from the M.D‟s. Audits are completed by the
month of October is signed off on with no reasoning as to nursing staff prior to the end of each shift to ensure orders
why the medication continues to be given. on the MAR are accurate. Audit results are submitted daily
Ibuprofen 400mg 1 tablet by mouth every 4 hours as to the Director of Nursing (DON) or their designee for
needed for pain. 10/16, 10/17, 10/18, and 10/21 given with review. The DON reports the results of the audits to the
no reasoning or resolution. monthly PI Council.
For I6 - Lithium Cit 8MEQ/5ML Syrup give 10ml by mouth The job descriptions for nursing staff have been revised to
twice daily. 10/31 not signed and no explanation as why not include information on the requirements and expectations
given. for medication administrator at the facility.
For I7 - Trazodone 100mg at bedtime on 10/2 not given and
no reason as to why. The facility ensures each nurse signs an attestation form
(supervision form) to acknowledge the importance in: Filling
For I8 - 8pm medications not signed on 10/1; Trazondone out MAR‟s, using first dose stamp, follow up on back of
50mg tab give one tab and Risperidone 0.5mg. 10/16 8am MAR, completing pain assessment form, and completing
Risperidone not signed and no reason as to why not given. incident forms / medication error forms. These forms are
filed in each nurses‟ personnel file.
For I9 - ERY Pads not signed off on 10/1; Seroquel 100mg
not signed off on 10/1 and 10/17; Ensure at bedtime, 8pm ACCEPTED
meds not signed on 10/1, 10/11, 10/17; Sertraline 50mg not
signed off/given on 10/16, 10/19 and 10/30.
For I10 - Haloperidol 0.5mg not signed/given on 10/1, 10/2,

10/17. Benzolyl Peroxide not signed/given on 10/1 and
Investigation ID:
10/17. Trazodone 100mg not given 10/1 and 10/17.

Oxcarbazepine 300mg not signed/given on 10/1 and 10/17.
Many of the PRNs viewed do not indicate reason for giving

and results.
On November 4, 2009 at 4pm OL Specialist went to the

girl‟s infirmary to verify control substance medications,
viewed nursing "packing" meds from PIXIS for 8PM
medications. Provider failed to follow their own policies
regarding the administration of medications.
For I6 - Medication Error Information Report dated 10/21/09

indicates that on 10/19 (and 10/20) "Wrote a order on
325mg. No allergic reaction - No known drug allergies - no
side effect." Transcribe order on wrong patient. Dated
10/21/09. MAR reviewed indicated three doses given and
progress notes reviewed do not indicate error or that Doctor
was notified.
For I18 - Resident was given one dose of a medication on

10/28/09 08:00 Doctor order placed in wrong chart, order
transcribed on Kardex. Resident‟s record did not record
incident of wrong administration of medication. There are
no physician notes which indicate notification the resident
was given wrong medications and assessed to ensure no
interactions with resident „s current medications. Resident
takes Depakote ER 500 Mg, three tabs ( 1500 mgs);
Femcor FE, Effexor, 75 mg; Concerta 36mg; Clonidine 0.1
mg; and Geodon 60mg.
For I19 - On 9/26/09, 10:30 AM, Resident was given

another residents meds in error on the unit. Wrong patient.
Distraction CLP Unit. Specialist Visit to the infirmary could
not identify which medications resident were administered.
There was no documentation in resident‟s record of the
incident and no record of physician notification and review
of the incident.
Additionally, Review of Medical record of I19 for September

reflects that resident received regular medication on
9/26/09, but no indication that wrong medications were
administered. There is no evidence Physician was notified
of error, nor is there evidence of what medications were
given. Physician ordered Motrin 400 mg p.o. tid for 5 days
Investigation ID:
then as needed Dr. Kim. L English, LPN documented

order on 9/15/09. A separate order reflects Ibuprofen 400
mg MCB 3GP give one tablet three times daily as needed
for pain. MAR reflects Motrin 400 Mg given at 7pm on
9/15/09 and on 9/24/09 at 2pm. No other documentation of
Ibuprofen administered in September 09. However, Pixis
report generated on 11/5/09 reflects that on 9/22/09 at 5:38
pm; 9/22/09 at 6:32; 9/24/09 at 1:38; 9/27/09 at 6:57 am; at
6:42 on 9/27; 10/3/09 at 7:05; 10/11/09 at 6:43 pm; and on
10/13/09 at 7:02 pm Ibuprofen was dispensed from the
Pixis machine for administration. Motrin was not
administered in accordance with the physicians order dated
9/15/09 where resident was to receive Motrin three days a
day for five days. Also, the MAR does not reflect the
administrations of the Motrin when dispensed by the Prixis
machine as listed above.
810.F - MARs contain NS For I1 - The facility now ensures that the MAR‟s contain date, drug 12/17/2009
date, drug Ibuprofen 400mg , give 1 tablet by mouth every 8 hours as name, schedule, strength, route, individual administering,
name,schedule,strengt need for pain. On 10/18 & 10/22 medication given but MAR and dates discontinued or changed. Audits are completed
h,route, individual does not have reason for or results indicated. by the nursing staff prior to the end of each shift. Audit
administering, dates Acetaminophen 325mg give 2 TABs by mouth every 4 results are submitted to the Director of Nursing (DON) or
dc'd or changed hours prn for H/A, body ache or Temp. On 10/14 & 10/29 their designee for review. The DON takes the results of
medication given but MAR does not have reason for or these audits to the monthly PI Council.
results indicated.
Nurses and therapists encourage medication compliance
For I2 - for all residents that refuse their medications. Medication
Ibuprofen 600mg 1 TAB by mouth every 6 hours as needed refusals are reported in morning meeting and referred to
for pain was given on 10/10; 10/12; 10/27; 10/29 @0215; their physician as needed.
10/29 @ 3:40pm; and 10/29 @ 11:50; 10/20 @ 3:10pm;
10/30 @ 9:30pm; 10/31 @ 5:30pm and 10/31 @ 0400 but Audits are completed by the nursing staff prior to the end of
no indication as to why or if resolved. each shift to ensure proper completion of the Medication
For I3 - daily to the Director of Nursing (DON) or their designee for
Abilify 2.5mg 8pm medication not signed or reason on review. The DON reports the results of the audits to the
10/10. monthly PI Council.
Terbinafine 1% cream apply to ringworm on chest at
bedtime til resolved or max of 4 weeks. The majority of the The facility ensures that all medication errors are
month of October is signed off on with no reasoning as to documented on a Medication Error repot, prior to leaving
why the medication continues to be given. the shift. This information is also documented on an
Ibuprofen 400mg 1 tablet by mouth every 4 hours as internal incident report and forwarded to the Risk Manager
needed for pain. 10/16, 10/17, 10/18, and 10/21 given with for reporting.
no reasoning or resolution.
Investigation ID:
The facility ensures that orders are correct on the MAR as

For I6 - Lithium Cit 8MEQ/5ML Syrup give 10ml by mouth changes come from the M.D‟s. Audits are completed by the
twice daily. 10/31 not signed and no explanation as why not nursing staff prior to the end of each shift to ensure orders
given. on the MAR are accurate. Audit results are submitted daily
For I7 - Trazodone 100mg at bedtime on 10/2 not given and to the Director of Nursing (DON) or their designee for
no reason as to why. review. The DON reports the results of the audits to the
monthly PI Council.
For I8 - 8pm medications not signed on 10/1; Trazondone
50mg tab give one tab and Risperidone 0.5mg. 10/16 8am The job descriptions for nursing staff have been revised to
Risperidone not signed and no reason as to why not given. include information on the requirements and expectations
for medication administrator at the facility.
not signed off on 10/1 and 10/17; Ensure at bedtime, 8pm The facility ensures each nurse signs an attestation form
meds not signed on 10/1, 10/11, 10/17; Sertraline 50mg not (supervision form) to acknowledge the importance in: Filling
signed off/given on 10/16, 10/19 and 10/30. out MAR‟s, using first dose stamp, follow up on back of
MAR, completing pain assessment form, and completing
For I10 - Haloperidol 0.5mg not signed/given on 10/1, 10/2, incident forms / medication error forms. These forms are
10/17. Benzolyl Peroxide not signed/given on 10/1 and filed in each nurses‟ personnel file.
Oxcarbazepine 300mg not signed/given on 10/1 and 10/17. ACCEPTED
Many of the PRNs viewed do not indicate reason for giving

and results.
On November 4, 2009 at 4pm OL Specialist went to the

girl‟s infirmary to verify control substance medications,
viewed nursing "packing" meds from PIXIS for 8PM
regarding the administration of medications.
810.G - Additional NS For I5 - Seroquel 100mg give 1 tab by mouth daily, 10/25 The facility ensures that all steps are taken in the case of a 12/17/2009
steps to take in case of medication not signed and no reason as to why not given. medication error or a drug reaction. Adverse reactions and
medication error or Ensure one bottle at bedtime not given on 10/5. side effects are reported to the physician and resident will
drug reaction For I1 - be evaluated by nursing and/or physician for necessary
Ibuprofen 400mg , give 1 tablet by mouth every 8 hours as medical response. Incident reports are completed for
need for pain. On 10/18 & 10/22 medication given but MAR adverse drug reactions
does not have reason for or results indicated.
Acetaminophen 325mg give 2 TABs by mouth every 4 Nurses and therapists encourage medication compliance
hours prn for H/A, body ache or Temp. On 10/14 & 10/29 for all residents that refuse their medications. Medication
medication given but MAR does not have reason for or refusals are reported in morning meeting and referred to
results indicated. their physician as needed.
For I2 - Audits are completed by the nursing staff prior to the end of
Ibuprofen 600mg 1 TAB by mouth every 6 hours as needed each shift to ensure proper completion of the Medication
for pain was given on 10/10; 10/12; 10/27; 10/29 @0215; Administration Record (MAR). Audit results are submitted
Investigation ID:
10/29 @ 3:40pm; and 10/29 @ 11:50; 10/20 @ 3:10pm; daily to the Director of Nursing (DON) or their designee for
10/30 @ 9:30pm; 10/31 @ 5:30pm and 10/31 @ 0400 but review. The DON reports the results of the audits to the
no indication as to why or if resolved. monthly PI Council.
For I3 - The facility ensures that all medication errors are

Abilify 2.5mg 8pm medication not signed or reason on documented on a Medication Error repot, prior to leaving
10/10. the shift. This information is also documented on an
Terbinafine 1% cream apply to ringworm on chest at internal incident report and forwarded to the Risk Manager
bedtime til resolved or max of 4 weeks. The majority of the for reporting.
month of October is signed off on with no reasoning as to
why the medication continues to be given. The facility ensures that orders are correct on the MAR as
Ibuprofen 400mg 1 tablet by mouth every 4 hours as changes come from the M.D‟s. Audits are completed by the
needed for pain. 10/16, 10/17, 10/18, and 10/21 given with nursing staff prior to the end of each shift to ensure orders
no reasoning or resolution. on the MAR are accurate. Audit results are submitted daily
For I9 - ERY Pads not signed off on 10/1; Seroquel 100mg review. The DON reports the results of the audits to the
not signed off on 10/1 and 10/17; Ensure at bedtime, 8pm monthly PI Council.
signed off/given on 10/16, 10/19 and 10/30. The job descriptions for nursing staff have been revised to
include information on the requirements and expectations
For I10 - Haloperidol 0.5mg not signed/given on 10/1, 10/2, for medication administrator at the facility.
10/17. Trazodone 100mg not given 10/1 and 10/17. The facility ensures each nurse signs an attestation form
Oxcarbazepine 300mg not signed/given on 10/1 and 10/17. (supervision form) to acknowledge the importance in: Filling
On November 4, 2009 at 4pm OL Specialist went to the MAR, completing pain assessment form, and completing
girl‟s infirmary to verify control substance medications, incident forms / medication error forms. These forms are
viewed nursing "packing" meds from PIXIS for 8PM filed in each nurses‟ personnel file.
regarding the administration of medications. ACCEPTED

was notified.
810.H - Medication NS REPEAT VIOLATION: ACCEPTED Corrected Action Plan The facility ensures that all medication refusals are 12/17/2009
refusals documented indicated that "The facility has ensured the revision of documented. Nurses and therapists encourage medication
policies, including, Medication Error Monitoring and compliance for all residents that refuse their medications.
Administration of Medication and Recording of and a new Medication refusals are reported in morning meeting and
policy was created, “Audits within the Infirmary”. All nurses referred to their physician as needed.
educated on new policies regarding documentation of the
Investigation ID:
MAR Nurses and therapists encourage medication compliance

As of 10-31-08, all orders for non-psychotropics / standard for all residents that refuse their medications. Medication
medications, i.e. acne medication, which are not used daily refusals are reported in morning meeting and referred to
will be discontinued or changed to PRN by the pediatrician." their physician as needed.
Provider Failed to follow-up on approved corrective action Audits are completed by the nursing staff prior to the end of
of 10/31/08. Also, provider failed to follow their own P&P, a each shift to ensure proper completion of the Medication
review of the MARs indicated a enormous amount of Administration Record (MAR). Audit results are submitted
refusals but the back of the MARs are not indicative as to daily to the Director of Nursing (DON) or their designee for
why. review. The DON reports the results of the audits to the
monthly PI Council.
The facility ensures that all medication errors are

documented on a Medication Error repot, prior to leaving
the shift. This information is also documented on an
internal incident report and forwarded to the Risk Manager
for reporting.

changes come from the M.D‟s. Audits are completed by the
nursing staff prior to the end of each shift to ensure orders
on the MAR are accurate. Audit results are submitted daily
review. The DON reports the results of the audits to the
monthly PI Council.
The job descriptions for nursing staff have been revised to

include information on the requirements and expectations
for medication administrator at the facility.
The facility ensures each nurse signs an attestation form

(supervision form) to acknowledge the importance in: Filling
incident forms / medication error forms. These forms are
ACCEPTED
810.I - P&P's for NS For I1 - The facility ensures that all medication administration 12/17/2009
reviewing medication Ibuprofen 400mg , give 1 tablet by mouth every 8 hours as policies are reviewed and updated with correct procedural
errors & making need for pain. On 10/18 & 10/22 medication given but MAR information.
improvements does not have reason for or results indicated.
Acetaminophen 325mg give 2 TABs by mouth every 4 Nurses and therapists encourage medication compliance
hours prn for H/A, body ache or Temp. On 10/14 & 10/29 for all residents that refuse their medications. Medication
medication given but MAR does not have reason for or refusals are reported in morning meeting and referred to
results indicated. their physician as needed.
Investigation ID:
For I2 - Audits are completed by the nursing staff prior to the end of
Ibuprofen 600mg 1 TAB by mouth every 6 hours as needed each shift to ensure proper completion of the Medication
for pain was given on 10/10; 10/12; 10/27; 10/29 @0215; Administration Record (MAR). Audit results are submitted
10/29 @ 3:40pm; and 10/29 @ 11:50; 10/20 @ 3:10pm; daily to the Director of Nursing (DON) or their designee for
10/30 @ 9:30pm; 10/31 @ 5:30pm and 10/31 @ 0400 but review. The DON reports the results of the audits to the
no indication as to why or if resolved. monthly PI Council.

Abilify 2.5mg 8pm medication not signed or reason on documented on a Medication Error repot, prior to leaving
10/10. the shift. This information is also documented on an
Terbinafine 1% cream apply to ringworm on chest at internal incident report and forwarded to the Risk Manager
bedtime til resolved or max of 4 weeks. The majority of the for reporting.
why the medication continues to be given. The facility ensures that orders are correct on the MAR as
Ibuprofen 400mg 1 tablet by mouth every 4 hours as changes come from the M.D‟s. Audits are completed by the
needed for pain. 10/16, 10/17, 10/18, and 10/21 given with nursing staff prior to the end of each shift to ensure orders
no reasoning or resolution. on the MAR are accurate. Audit results are submitted daily
For I7 - Trazodone 100mg at bedtime on 10/2 not given and review. The DON reports the results of the audits to the
no reason as to why. monthly PI Council.
For I8 - 8pm medications not signed on 10/1; Trazondone The job descriptions for nursing staff have been revised to
50mg tab give one tab and Risperidone 0.5mg. 10/16 8am include information on the requirements and expectations
Risperidone not signed and no reason as to why not given. for medication administrator at the facility.
For I9 - ERY Pads not signed off on 10/1; Seroquel 100mg The facility ensures each nurse signs an attestation form
not signed off on 10/1 and 10/17; Ensure at bedtime, 8pm (supervision form) to acknowledge the importance in: Filling
meds not signed on 10/1, 10/11, 10/17; Sertraline 50mg not out MAR‟s, using first dose stamp, follow up on back of
signed off/given on 10/16, 10/19 and 10/30. MAR, completing pain assessment form, and completing
For I10 - Haloperidol 0.5mg not signed/given on 10/1, 10/2, filed in each nurses‟ personnel file.
10/17. Trazodone 100mg not given 10/1 and 10/17. ACCEPTED
The majority of the residents on the Compass unit did not
have meds signed/given on 10/1 and 10/17 at 8pm.
For I13 - MAR for Jan.09:

Singular 10 mg tab mcb give 1 tab by mouth at bedtime.
Provider failed to document on 1/14/09 whether Resident
received his medication. Medication not signed for.
MAR for April 2009:
Seroquel 400 mg tablet give 1 tab by mouth twice daily 8:00
am medication not given for 4/1/09
Adderall XR 20 mg capsule Give 1 cap by mouth daily for
Investigation ID:
impulsivity 8:00 am medication not given 4/1/09

Paroxetine 20 mg tab mcb Paxil 20 mg tablet give 1 tab by
mouth daily for depression 8:00 am 4/1/09
MAR for May 2009:

Singulair 10 mg mcb 3igp Give 1 tab by mouth at bedtime;
Provider failed to administered medication for Resident AH.
No documentation that medication was administered for
5/13/09; and 05/25/09.
MAR for July 2009:

Seroquel 100 mg by mouth twice daily with 400mg = 500mg
- Provider failed to document whether Resident AH received
medication for 10/31/09- No documentation whether
medication was given.
The Following staff did not sign the back of the mar for July
2009- Staff RGB: Staff SH; Staff SL
MAR for Aug 2009:

8/12/09- 8:00pm Seroquel 100 mg mcb gp give 1 tab by
mouth twice daily (W/400=500mg) no documentation that
medications were administered
MAR for September 2009: - Seroquel 100 mg mcb Give 1

tab by mouth twice daily 8 pm 9/04/09-Provider failed to
document that medication for this resident was
administered on this date. No documentation that
For October 2009: Trazodone 50 mg tablet Give 1 tab by

mouth at bedtime for sleep; 8 pm 10/02
Adderall XR 20 mg capsule Give 1 Cap by mouth daily-
10/2/09 Staff RM did not sign the back of the Mar
Seroquel 100mg mcb Give 1 tab by mouth twice daily 8:pm-
10/2/09- Provider failed to document whether medication
was administered.
Singulair 10 mg mcb 8:pm-10/2 & 3/09- Provider failed to
document whether medication was administered. No
documentation on the mar.
Seroquel 400 mg mcb gp Give 1 tab by mouth twice daily-
8:00pm- 10/2/09- Provider failed to document whether
medication was administered.
Retin-A Micro 0.4% gel apply to facial acne at bedtime 8
pm-10/02/09- Provider failed to document whether
Investigation ID:
For I16 - Medication Error Information Report dated

10/21/09 indicates that on 10/19 (and 10/20) "Wrote a order
on wrong resident - Resident had received one Ferrous
Sulfate 325mg. No allergic reaction - No known drug
allergies - no side effect." Transcribe order on wrong
patient. Dated 10/21/09. MAR reviewed indicated three
doses given and progress notes reviewed do not indicate
error or that Doctor was notified.
For I17 - October 2009 MAR:

Progress note on 10/10/09 @ 11:10 pm by staff Cornelia
Epp indicated the following: Resident was @ infirmary
getting meds, horse playing, refusing to take meds.
Resident started getting verbally aggressive /threats
towards nursing staff, being disruptive, defiant oppositional.
However the medication administration record indicated that
the mediation was administered. Trazodone 100 mg tab gp
ic give 1 tab y mouth at bedtime.
Staff PR failed to sign the back of Mar for Resident MF.

Staff NT did not place signature on the back of the mar for
Resident MF. Signature space is without signature dated
10/18/09.
MAR for September 2009:

Ibuprofen 600 mg mcb 3 gpe Give 1 tab by mouth every 6
hours prn headache or pain; Provider failed to document
PRN medication for the following dates that medication
was administered on these date 10/2; 10/7; 10/12; 10/21;
10/22; & 10/28/09.
MAR for June 2009:

Trazodone 100 mg by mouth daily at bedtime: The following
staff failed to properly document the back of the mar after
administering medication for Resident MF; Staff PM; DR;
PE;
Staff M.Ross RN used a stamp to sign the back of the mar.
No Signature for June 2009 mar.
Vyvanese 20 mg by mouth every am; Staff NA
Provider failed to document the back of the mar for

Resident MF June 2009 mar for Naproxen 500 mg MCB 3ig
Give 1 tab by mouth twice daily with food prn for pain. Staff
administered medication for the following dates with signing
back of MAR 6/3; 6/5; 6/8; 6/9; 6/13; 6/13; 6/15;6/17/09
Motrin 600 mg by mouth q 60 prn for pain. Provider failed to
Investigation ID:
properly document mar for Resident MF 6/19/09 & 6/23/09
Physician's Order dated 729/09 Debrox for ear wax removal

3 drops tid for three days, then flush on the fourth day with
warm water. S.o Dr. Kim/
Provider failed to properly follow the medication order for
Resident MF. This medication was administered at the
following times 8:00am; 2 :00 pm and 8:00 pm; The
medication was administered on the following dates; Only
administered 7/29;30; and 31/09 for 8:00 pm . Also mar for
Aug 2009 this same medication was not administered for
8/3/09@ 2pm & 8pm; Also the back of the mar read for
8/9/09 & 8/13/09 "debrox didn't come". Documentation on
the mar indicate that this medication was on Aug 7, 8,9,10,
11,13.15, &16/09 Medication was discharged 8/17/09.

Trazodone 100 mg gp ic given 1 tab by mouth at bedtime:
8pm- Provider failed to document that medication was
administered on 9/9/09. No documentation on mar that
820.A - Three balanced N - Baking area was dirty. The facility ensures that residents receive three balanced 12/02/2009
meals and snack - Baking oven was dirty. meals and snacks per day. The dietician reviews and
- Turkey wrapped did not have a date. approves the monthly menus. Each resident is seen by the
- There was Rib-Eye dated 5/31/07 in the freezer! facility dietician at admission and is monitored monthly by
- Danishes not dated. nursing and physician for proper weight and diet.
- Loaf of bread with expired date of 10/29/09 was being
used. Bread placed back in the area after OL Specialist The facility ensures that the kitchen and cafeteria areas are
instructed it needed to be thrown out. clean and sanitary at all times. The Kitchen Manager
provides weekly walk throughs of the area and now checks
for expired food items, which will be disposed of as soon as
item is found. And all items are dated as soon as they are
opened. Dietary completes quarterly updates to PI Council
in regards to menus, meals, and resident needs.
ACCEPTED
890.A - Adequate N Several resident rooms inspected had dirty clothes up to the The facility ensures that the residents have an adequate 12/02/2009
supply of clean, top of the hamper. Provider unable to determine when the supply of clean clothing and shoes. Resident needs are
comfortable clothes residents do laundry and/or scheduled. reported to the case manager to address with family and/or
and shoes referring agency. The posted schedules did not indicate the
day of the week each individual was responsible for
washing clothing.
During the tour, the bedrooms were clean, but had dirty
clothing in basket which caused room to smell stale. The
Unit Managers ensures residents wash clothing on
Investigation ID:
scheduled day.
The facility ensures the buildings are well ventilated and

free of foul odors. Bedrooms were clean, but had dirty

ACCEPTED
960.A - Clean, N Several resident rooms inspected had dirty clothes up to the The facility ensures the residents have adequate, well fitting 12/02/2009
adequate, well-fitting top of the hamper. Provider unable to determine when the clothing. The facility ensures residents wash clothing on
clothing residents do laundry and/or scheduled scheduled day and will assist residents as needed to
ensure laundry does not pile up. Resident needs are
reported to the case manager to address with family and/or
referring agency.
During the tour, the bedrooms were clean, but had dirty
scheduled day.
The facility ensures the buildings are well ventilated and

free of foul odors. Bedrooms were clean, but had dirty

ACCEPTED
970.B - Policy re NS Provider failed to follow their own policy and procedures The facility ensures policies and systems are in place to 02/08/2010
allowances regarding personal allowances. A review of several appropriately handle resident money on the units. All units
Investigation ID:
resident ledgers indicated money that the resident's were now have lockboxes to keep resident funds secure.
able to make purchases but there is no documentation Residents sign off when money is received and returned to
substantiating purchases. help track for accuracy. Unit Managers audit the forms and
the money monthly and report finding to the Director of
Residential Services. This information is also brought to the
monthly PI Council meetings.
PARTIALLY ACCEPTED: PROVIDER NEEDS TO

COMPLETE AN INTERNAL AUDIT OF ALL RESIDENTS
PERSONAL MONIES IN ORDER TO PROPERLY
ACCOUNT IF RESIDENTS SPENT MONIES DISPURSED.
IF MONIES ARE FOUND TO BE UNACCOUNTED FOR
PROVIDER NEEDS TO DETERMINE NEXT STEP TO
REIMBURSE THOSE FUNDS.
The facility completed an audit on all resident funds to

determine: Security of funds on unit, amount of cash on
hand, and verification of resident signatures. The facility
ensures that resident funds audits are completed in the
business office and on the unit monthly. This information is
reported in the monthly PI Council meetings.
ACCEPTED
M130 - P&P for NS For I1 - The facility ensures an environment for safe medication 12/17/2009
administering of Ibuprofen 400mg, give 1 tablet by mouth every 8 hours as administration is provided to reduce the possibility of
prescription & OTC need for pain. On 10/18 & 10/22 medication given but MAR medication errors. Audits are completed by the nursing
medications does not have reason for or results indicated. staff prior to the end of each shift to ensure proper
Acetaminophen 325mg give 2 TABs by mouth every 4 completion of the Medication Administration Record (MAR).
hours prn for H/A, body ache or Temp. On 10/14 & 10/29 Audit results will be submitted daily to the Director of
medication given but MAR does not have reason for or Nursing (DON) or their designee for review. The DON
results indicated. reports the results of the audits to the monthly PI Council.

Ibuprofen 600mg 1 TAB by mouth every 6 hours as needed documented on a Medication Error repot, prior to leaving
for pain was given on 10/10; 10/12; 10/27; 10/29 @0215; the shift. This information is documented on an internal
10/29 @ 3:40pm; and 10/29 @ 11:50; 10/20 @ 3:10pm; incident report and forwarded to the Risk Manager for
10/30 @ 9:30pm; 10/31 @ 5:30pm and 10/31 @ 0400 but reporting.
no indication as to why or if resolved.
For I3 - changes come from the M.D‟s.
Abilify 2.5mg 8pm medication not signed or reason on
10/10. The job descriptions for nursing staff have been revised to
Terbinafine 1% cream apply to ringworm on chest at include information on the requirements and expectations
bedtime til resolved or max of 4 weeks. The majority of the for medication administrator at the facility.
why the medication continues to be given. The facility ensures each nurse signs an attestation form
Ibuprofen 400mg 1 tablet by mouth every 4 hours as (supervision form) to acknowledge the importance in: Filling
Investigation ID:
needed for pain. 10/16, 10/17, 10/18, and 10/21 given with out MAR‟s, using first dose stamp, follow up on back of
no reasoning or resolution. MAR, completing pain assessment form, and completing
For I7 - Trazodone 100mg at bedtime on 10/2 not given and filed in each nurses‟ personnel file.
no reason as to why.
ACCEPTED
For I8 - 8pm medications not signed on 10/1; Trazondone
50mg tab give one tab and Risperidone 0.5mg. 10/16 8am
Risperidone not signed and no reason as to why not given.

not signed off on 10/1 and 10/17; Ensure at bedtime, 8pm

The majority of the residents on the Compass unit did not
have meds signed/given on 10/1 and 10/17 at 8pm.

indicates that on 10/19 (and 10/20) "Wrote an order on
was notified.
M130.A.1.b - Any NS For I16 - Resident given another resident's medication, no The facility ensures documentation of adverse reactions or 12/17/2009
adverse reactions or documentation of any immediate action taken by Dr. or that suspected side effects from medications. Adverse
suspected side effects a Dr. was ever notified. MARs signed as if residents own reactions and side effects are reported to the physician and
medication was given. resident will be evaluated by nursing and/or physician for
necessary medical response. Incident reports are
completed for adverse drug reactions. Audits are
completed by the nursing staff prior to the end of each shift
to ensure proper completion of the Medication
daily to the Director of Nursing (DON) or their designee for
monthly PI Council.
The facility ensures that all medication errors are

documented on a Medication Error repot, prior to leaving
Investigation ID:
the shift. This information is documented on an internal

incident report and forwarded to the Risk Manager for
reporting.

changes come from the M.D‟s.
ACCEPTED
M130.A.3 - NS The majority of the residents on the Compass unit did not The facility ensures documentation of medication errors and 12/17/2009
Documentation of have meds signed/given on 10/1 and 10/17 at 8pm. drug reactions. Adverse reactions and side effects are
medication errors & reported to the physician and resident will be evaluated by
drug reactions For I1 - nursing and/or physician for necessary medical response.
Ibuprofen 400mg, give 1 tablet by mouth every 8 hours as Assessments and actions taken will be documented in the
need for pain. On 10/18 & 10/22 medication given but MAR resident chart. Incident reports are completed for adverse
does not have reason for or results indicated. drug reactions. Audits are completed by the nursing staff
Acetaminophen 325mg give 2 TABs by mouth every 4 prior to the end of each shift to ensure proper completion of
hours prn for H/A, body ache or Temp. On 10/14 & 10/29 the Medication Administration Record (MAR). Audit results
medication given but MAR does not have reason for or are submitted daily to the Director of Nursing (DON) or their
results indicated. designee for review. The DON reports the results of the
audits to the monthly PI Council.
For I2 -
Ibuprofen 600mg 1 TAB by mouth every 6 hours as needed The facility ensures that all medication errors are
for pain was given on 10/10; 10/12; 10/27; 10/29 @0215; documented on a Medication Error repot, prior to leaving
10/29 @ 3:40pm; and 10/29 @ 11:50; 10/20 @ 3:10pm; the shift. This information is documented on an internal
10/30 @ 9:30pm; 10/31 @ 5:30pm and 10/31 @ 0400 but incident report and forwarded to the Risk Manager for
no indication as to why or if resolved. reporting.
For I3 - The facility ensures that orders are correct on the MAR as
Abilify 2.5mg 8pm medication not signed or reason on changes come from the M.D‟s.
10/10.
Terbinafine 1% cream apply to ringworm on chest at The job descriptions for nursing staff have been revised to
bedtime til resolved or max of 4 weeks. The majority of the include information on the requirements and expectations
month of October is signed off on with no reasoning as to for medication administrator at the facility.
why the medication continues to be given.
Ibuprofen 400mg 1 tablet by mouth every 4 hours as The facility ensures each nurse signs an attestation form
needed for pain. 10/16, 10/17, 10/18, and 10/21 given with (supervision form) to acknowledge the importance in: Filling
no reasoning or resolution. out MAR‟s, using first dose stamp, follow up on back of
For I7 - Trazodone 100mg at bedtime on 10/2 not given and incident forms / medication error forms. These forms are
no reason as to why. filed in each nurses‟ personnel file.
For I8 - 8pm medications not signed on 10/1; Trazondone ACCEPTED

50mg tab give one tab and Risperidone 0.5mg. 10/16 8am
Risperidone not signed and no reason as to why not given.

Investigation ID:
not signed off on 10/1 and 10/17; Ensure at bedtime, 8pm


For I13 - MAR for Jan.09:

Singular 10 mg tab mcb give 1 tab by mouth at bedtime.
Provider failed to document on 1/14/09 whether Resident
received his medication. Medication not signed for.
MAR for April 2009:
Seroquel 400 mg tablet give 1 tab by mouth twice daily 8:00
am medication not given for 4/1/09
Adderall XR 20 mg capsule Give 1 cap by mouth daily for
impulsivity 8:00 am medication not given 4/1/09
Paroxetine 20 mg tab mcb Paxil 20 mg tablet give 1 tab by
mouth daily for depression 8:00 am 4/1/09
MAR for May 2009:

Singulair 10 mg mcb 3igp Give 1 tab by mouth at bedtime;
Provider failed to administered medication for Resident AH.
No documentation that medication was administered for
5/13/09; and 05/25/09.
MAR for July 2009:

Seroquel 100 mg by mouth twice daily with 400mg = 500mg
- Provider failed to document whether Resident AH received
medication for 10/31/09- No documentation whether
The Following staff did not sign the back of the mar for July
2009- Staff RGB: Staff SH; Staff SL
MAR for Aug 2009:

8/12/09- 8:00pm Seroquel 100 mg mcb gp give 1 tab by
mouth twice daily (W/400=500mg) no documentation that
medications were administered
MAR for September 2009: - Seroquel 100 mg mcb Give 1

tab by mouth twice daily 8 pm 9/04/09-Provider failed to
document that medication for this resident was
administered on this date. No documentation that
Investigation ID:
For October 2009: Trazodone 50 mg tablet Give 1 tab by

mouth at bedtime for sleep; 8 pm 10/02
Adderall XR 20 mg capsule Give 1 Cap by mouth daily-
10/2/09 Staff RM did not sign the back of the Mar
Seroquel 100mg mcb Give 1 tab by mouth twice daily 8:pm-
10/2/09- Provider failed to document whether medication
was administered.
Singulair 10 mg mcb 8:pm-10/2 & 3/09- Provider failed to
document whether medication was administered. No
documentation on the mar.
Seroquel 400 mg mcb gp Give 1 tab by mouth twice daily-
8:00pm- 10/2/09- Provider failed to document whether
Retin-A Micro 0.4% gel apply to facial acne at bedtime 8
pm-10/02/09- Provider failed to document whether
For I16 - Medication Error Information Report dated

10/21/09 indicates ton on 10/19 (and 10/20) "Wrote a order
on wrong resident - Resident had received one Ferrous
Sulfate 325mg. No allergic reaction - No known drug
allergies - no side effect." Transcribe order on wrong
patient. Dated 10/21/09. MAR reviewed indicated three
doses given and progress notes reviewed do not indicate
error or that Doctor was notified.
For I17 - October 2009 MAR:

Progress note on 10/10/09 @ 11:10 pm by staff Cornelia
Epp indicated the following: Resident was @ infirmary
getting meds, horse playing, refusing to take meds.
Resident started getting verbally aggressive /threats
towards nursing staff, being disruptive, defiant oppositional.
However the medication administration record indicated that
the mediation was administered. Trazodone 100 mg tab gp
ic give 1 tab y mouth at bedtime.
Staff PR failed to signs the back of Mar for Resident MF.

Staff NT did not place signature on the back of the mar for
Resident MF. Signature space is without signature dated
10/18/09.

Ibuprofen 600 mg mcb 3 gpe Give 1 tab by mouth every 6
hours prn headache or pain; Provider failed to document
PRN medication for the following dates that medication
was administered on these date 10/2; 10/7; 10/12; 10/21;
Investigation ID:
10/22; & 10/28/09.
MAR for June 2009:

TTrazodone100 mg by mouth daily at bedtime: The
following staff failed to properly document the back of the
mar after administering medication for Resident MF; Staff
PM; DR; PE;
Staff M.Ross RN used a stamp to sign the back of the mar.
No Signature for June 2009 mar.
Vyvanese 20 mg by mouth every am; Staff NA
Provider failed to document the back of the mar for

Resident MF June 2009 mar for Naproxen 500 mg MCB 3ig
Give 1 tab by mouth twice daily with food prn for pain. Staff
administered medication for the following dates with signing
back of MAR 6/3; 6/5; 6/8; 6/9; 6/13; 6/13; 6/15;6/17/09
Motrin 600 mg by mouth q 60 prn for pain. Provider failed to
properly document mar for Resident MF 6/19/09 & 6/23/09
Physician's Order dated 729/09 Debrox for ear wax removal

3 drops tid for three days, then flush on the fourth day with
warm water. S.o Dr. Kim/
Provider failed to properly follow the medication order for
Resident MF. This medication was administered at the
following times 8:00am; 2 :00 pm and 8:00 pm; The
medication was administered on the following dates; Only
administered 7/29;30; and 31/09 for 8:00 pm . Also mar for
Aug 2009 this same medication was not administered for
8/3/09@ 2pm & 8pm; Also the back of the mar read for
8/9/09 & 8/13/09 "debrox didn't come". Documentation on
the mar indicates that this medication was on Aug 7, 8,9,10,
11,13.15, &16/09 Medication was discharged 8/17/09.

Trazodone 100 mg gp ic given 1 tab by mouth at bedtime:
8pm- Provider failed to document that medication was
administered on 9/9/09. No documentation on mar that
M140 - Quarterly NS Provider failed to properly respond to medication error The facility now ensures that there is a quarterly review of 12/17/2009
review of med errors to reports. There is no documentation supporting that medication errors in PI Council. This review will include any
include staff quarterly review of med errors occurs. noted trends as well as staff development needs. Audits
development needs are completed by the nursing staff prior to the end of each
For I7 - Resident refused 8pm Trazodone for a number of shift to ensure proper completion of the Medication
days in October but there is no indication that the Dr. Administration Record (MAR). Audit results are submitted
Investigation ID:
responded to this issue. daily to the Director of Nursing (DON) or their designee for
For I6 - Medication Error Information Report dated 10/21/09 monthly PI Council.
wrong resident - Resident had received one Ferrous Sulfate The facility ensures that all medication errors are
325mg. No allergic reaction - No known drug allergies - no documented on a Medication Error repot, prior to leaving
side effect." Transcribe order on wrong patient. Dated the shift. This information is documented on an internal
10/21/09. MAR reviewed indicated three doses given and incident report and forwarded to the Risk Manager for
progress notes reviewed do not indicate error or that Doctor reporting.
was notified.
Several Medication Error Information Reports, dated changes come from the M.D‟s.
10/3/2009 were reviewed which documented a failure by
the Provider‟s program of medication used to monitor the The job descriptions for nursing staff have been revised to
ordering and accounting for medications. On October 3, include information on the requirements and expectations
2009, an RN documented that the Provider‟s Pixis for medication administrator at the facility.
Computer had either wrong medications listed for resident
or wrong dosages listed for residents. Even though the RN The facility ensures each nurse signs an attestation form
documented these systems errors, there was no evidence (supervision form) to acknowledge the importance in: Filling
found that Provider researched the causes for these noted out MAR‟s, using first dose stamp, follow up on back of
discrepancies or took action to correct the errors. The MAR, completing pain assessment form, and completing
following are the errors or potential for errors documented: incident forms / medication error forms. These forms are
1. Resident I3 - Remeron 7.5 mg prescribed for resident
does not show on Pixis items list. Prescription show up in ACCEPTED
view orders. Resident needs drug loaded in pixis.
2. Resident I22 - 10/3/09;1600; Residents anticoagulant is

inaccessible. The generic Warfarin shows on patients view
orders as not loaded in this station, but the brand name
Jantovin is in inventory. Generic and Brand Name
confusion with pixis.

error. Resident has not been prescribed Lithium. Drug is
listed on his profile as Lithium 300 Mg, Give one CAP by
mouth at bedtime for impulse.

error. Resident has not been prescribed the drug
Clonazepam. Drug is listed on his profile as Clonazepam
0.25 mg inject as directed by physician.
5. Resident I24 - Potential for overdose. Resident‟s

Seroquel was increased from 600 mg to 700 mg. The order
used to read “Seroquel 300mg – give 2 tabs at bedtime”.
Investigation ID:
Pharmacy added an order for “Seroquel 400 mg. Give 1

Tab at bedtime. Pixis still reads give 2 -300 mg tabs (plus
the new 400 mg =1000mg). Improper dose/quantity.
6. Resident 25 - Resident has been on Ducosate 100 mg

since her admission in 2008. Drug is inaccessible now. It
does not show on patient‟s item list. It does show on view
orders list but states, “ not loaded in this station”. Drug is in
inventory.
Specialist interviewed the staff responsible for maintaining

the system at the time of these noted discrepancies and
was informed that the discrepancies had not been
investigated as they thought the RN‟s documenting these
errors was unnecessary. Therefore, no action has been
taken to ensure resident‟s medication prescription profiles
and orders are documented correctly in Provider‟s
medication Program (Prixis). Potential for abuse.
M200 - Serious NS For I15 - On 11/3/09, OL Specialist was interviewing The facility ensures that any serious incident is reported 02/12/2010
incidents reported residents on the Compass Unit when resident I15 described within 24 hours to the placing agency, regulatory agencies
within 24 hours, to an incident that occurred on 10/30/09. Provider failed to and the parent/guardian and noted on the incident report.
include: report serious incident involving resident, I15 , within
24hours. On October 30, 2009, resident indicated to staff The facility ensures that all required and requested
that he did not want to live, turned down the hall and ran incidents are reported to the licensure department on a
head first into the exit door. Video confirmed the incident Serious Incident Report (SIR), per Interdepartmental
and showed that the resident was unconscious for regulations and per conversations with Licensure. The
approximately 1 minute, 55 seconds. Video also showed facility currently reports accidents or injuries requiring
that staff failed to ensure resident's health & safety but not medical attention, elopements, allegations of abuse/neglect,
attending to him, and when nurse arrived on the unit she did serious infractions of facility rules, suspected drug abuse,
not assess the resident. Physician was not notified of the accusations of criminal conduct, serious illnesses, serious
incident and medical attention was not sought. Video also altercations with staff or peer, any self-harm or threat of
showed that after staff escorted resident to his bedroom self-harm, contraband found, suicidal gestures, and any
that the nurse was seen at the door way and did not assess events causing impact on rights / responsibilities of legal
the resident. guardian.
For I16 - Provider failed to submit a serious incident report The facility ensures that significant medication errors are
within 24hrs. On 10/19/09 the Medication Error Information also reported on an SIR within 24 hours.
Report indicates "Wrote a order on wrong resident -
Resident had received one Ferrous Sulfate 325mg. No All incident reports are reviewed in morning meeting by the
allergic reaction - No known Drug allergies - No side effect." Risk Manager, or designee. The morning meeting involves
Report prepared on 10/21/09. all campus disciplines and all incidents from the previous
I18 - Medication Error Information Report, dated 10/28/09, on an incident report. It is through these incident reports
indicates "Doctor order placed in wrong chart, order that the Risk Manager compiles the SIR for Licensure.
Investigation ID:
transcribed on Kardex - resident given one dose, no

adverse side effect from medication." The campus Risk Manager reviews daily and audits
I19 - Provider failed to report serious incident within 24 parties. The audit is reported monthly in PI Council.
hours. Medication Error Information Report, dated 9/26/09,
indicates " Resident was given another residents meds in After sending off the SIR, the facility follows up with an
error on the unit." Review of the documentation indicates email to DBHDS with an account of all faxed reports for that
that there is no nursing notes indicating the error; provider day. The campus Administrator, Director of Performance
failed to notify a Physician of the error and the MAR Improvement, and the CEO receive this information daily for
indicates that the resident received her medication as well. tracking purposes.
I22 - Provider failed to report serious incident within 24 PARTIALLY ACCEPTED:

hours. Risk Management - Incident Reporting form dated, PROVIDER NEEDS TO DEVELOP PROCEDURES FOR
10/24/09, "Medication notTrascripteddd from CHKD THE SAFE GUARDING OF VIDEO FOOTAGE RELATING
Discharged Instruction - Zofran 8mg + Bactroban." TO SERIOUS INCIDENTS UNTIL ALL INVESTIGATIONS
Medication Error Information Report dated 10/24/09 HAVE BEEN COMPLETED.
indicated "Medication not Tran scripted from Discharged
Instruction Medication list. One LPN says the medication The facility ensures that video footage is safeguarded as it
was placed on the MAR and one LPN says it was not; relates to serious incidents. The Risk Manager is
medication was Coumadin. responsible for saving this footage as soon as he/she is
ACCEPTED (M200 - M200B)
M200.A.1 - Date and NS Cited the same as M200. The facility ensures that serious incident reports are 02/12/2010
time submitted within 24 hours and include date and time of
incident.

incidents are reported to the licensure department on a
guardian.


Investigation ID:


parties. The audit is reported monthly in PI Council.

tracking purposes.
M200.A.2 - Brief NS Cited the same as M200. The facility ensures that serious incident reports are 02/12/2010
Description submitted within 24 hours and include date and time of
incident.

guardian.



Investigation ID:

tracking purposes.
M200.A.3 - Action NS Cited the same as M200. The facility ensures that serious incident reports are 02/12/2010
taken as a result of the submitted within 24 hours and include date and time of
incident incident.

guardian.




tracking purposes.
M200.A.4 - Name of NS Cited the same as M200. The facility ensures that serious incident reports are 02/12/2010
person completing the submitted within 24 hours and include date and time of
report incident.
Investigation ID:

guardian.




tracking purposes.
M200.A.5 - Name of NS Cited the same as M200. The facility ensures that serious incident reports are 02/12/2010
person making report submitted within 24 hours and include date and time of
to applicable parties incident.

Investigation ID:

guardian.




tracking purposes.
M200.A.6 - Names of NS Cited the same as M200. The facility ensures that serious incident reports are 02/12/2010
persons to whom submitted within 24 hours and include date and time of
reports were made incident.

guardian.


Investigation ID:



tracking purposes.
M200.B - Serious NS Cited the same as M200. The facility ensures that serious incident reports are 02/12/2010
injury/deaths reported submitted within 24 hours and include serious injury/deaths
on approved forms reported on approved forms.

guardian.



Investigation ID:

tracking purposes.
M30 - Guaranteed NS Cited the same as M200. The facility ensures that all Human Rights policies and 02/12/2010
Human Rights procedures are followed and enforced. The facility ensures
For I15 - On October 30, 2009, provider failed to properly that any serious incident is reported within 24 hours to the
seek medical treatment in accordance to sound therapeutic placing agency, regulatory agencies and the
practice. Resident ran into the door and was unconscious parent/guardian and noted on the incident report.
for almost two minutes and was not properly assessed by
nursing staff and was not sent to the ER. Staff interviewed The facility ensures that all required and requested
on 11/9/09 indicated that the resident also had a cut on top incidents are reported to the licensure department on a
of the head, reason why staff had gloves on. Serious Incident Report (SIR), per Interdepartmental
Provider failed to ensure that resident's have and spend facility currently reports accidents or injuries requiring
personal money. Review of client funds indicate that the medical attention, elopements, allegations of abuse/neglect,
provider has no formal written process to account for serious infractions of facility rules, suspected drug abuse,
personal monies allocated to resident. Interview of McCall accusations of criminal conduct, serious illnesses, serious
Program Manager indicated that resident's cannot have any altercations with staff or peer, any self-harm or threat of
personal monies, $5.00. One staff interview that if a self-harm, contraband found, suicidal gestures, and any
resident has money on there possession it is considered a events causing impact on rights / responsibilities of legal
contraband. guardian.
The facility ensures that medication errors are also reported

on an SIR within 24 hours.

tracking purposes. Then during the daily morning meetings
with the executive team, the PI Director or designee discuss
the reports sent the prior day.
All incident reports are reviewed in morning meeting. The

campus Risk Manager reviews daily and audits monthly all
incident reports for 24 hour notification of all parties. The
audit is reported monthly in PI Council. The morning
meeting involves all campus disciplines and all incidents
from the previous day are discussed to ensure that all
incidents were captured on an incident report. It is through
these incident reports that the Risk Manager compiles the
Investigation ID:
SIR for Licensure.
The facility ensures written policies exist to help regulate

and account for resident money. Policies were under
revision during the review so both the current policy and the
new policy were shared. The new policy is now fully
implemented,
The facility ensures systems are in place to appropriately

handle resident money on the units. All units now have
lockboxes to keep resident funds secure. Residents sign
off when money is received and returned to help track for
accuracy. Unit Managers audit the forms and the money
monthly and report finding to the Director of Residential
Services. This information is also brought to the monthly PI
Council meetings.
PARTIALLY ACCEPTED:
PARTIALLY ACCEPTED: PROVIDER NEEDS TO

COMPLETE AN INTERNAL AUDIT OF ALL RESIDENTS
PERSONAL MONIES IN ORDER TO PROPERLY
ACCOUNT IF RESIDENTS SPENT MONIES DISBURSED.
IF MONIES ARE FOUND TO BE UNACCOUNTED FOR
PROVIDER NEEDS TO DETERMINE NEXT STEP TO
REIMBURSE THOSE FUNDS.

ACCEPTED
The facility completed an audit on all resident funds to

determine: Security of funds on unit, amount of cash on
hand, and verification of resident signatures. The facility
ensures that resident funds audits are completed in the
business office and on the unit monthly. This information is
reported in the monthly PI Council meetings.
ACCEPTED
Investigation ID:
Investigation ID:
General Comments / Recommendations:

An unannounced licensure renewal visit was completed on November 3, 2009 thru November 9, 2009. OL Specialists, Ed Gonzalez, Barry Lee and Dennis Riddick,
completed annual review. Specialists are concerned with the health and safety of residents at this facility.
This unannounced inspection revealed widespread programmatic and systemic deficiencies including, substandard training by staff pertaining to emergency medical
response, mishandling of serious medication errors, poor execution of skilled nursing practices, lack of attention to detail pertaining to medication administration
protocols, a reckless disregard for the health and safety of a resident who required immediate medical attention, inability to adequately demonstrate internal financial
controls regarding resident’s finances, lack of communication among administrative and line staff regarding disseminating agency operational policies and
procedures, lack of supervision by staff to ensure that resident have safety coverage during hours of operation, and failure to report serious incident reports to
governing agencies for compliance.
Individual service records were reviewed, P&P were reviewed; personnel records were reviewed; environmental review was completed and residents/staff were
interviewed. This unannounced inspection ended with an exit interview with the administrative and executive staff. Please submit acceptable corrective action by
December 23, 2009 to: Ed.Gonzalez@DBHDS.Virginia.Gov
PLEASE SUBMIT ACCEPTABLE CORRECTIVE ACTION ON ITEMS NOTEDS AS "NOT ACCEPTED OR PARTIALLY ACCEPTED BY FEBRUARY 10, 2010 TO:
Ed.Gonzalez@DBHDS.Virginia.Gov
I understand it is my right to request a conference with the reviewer and the reviewer‟s supervisor should I desire further discussion of these findings. By my signature on the
Corrective Action Plan, I pledge that the actions to be taken will be completed as identified by the date indicated.
_________________________ _____________________________________ __________

Ed Gonzalez, Specialist (Signature of Organization Representative) Date
Mail to: 2100 Steppingstone Square Due Date: 12-23-2009

Chesapeake. VA 23320
C = Substantial Compliance, N = Non Compliance, NS = Non Compliance Systemic, ND = Non Determined

The Pines Residential Treatment Center 11/09 Inspection

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The Pines Residential Treatment Center 11/09 Inspection

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DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES

CORRECTIVE ACTION PLAN Page: 1 of 71

responsible for saving this footage as soon as he/she is

The facility ensures that all required and requested

The facility ensures that significant medication errors are

All incident reports are reviewed in morning meeting by the

The campus Risk Manager reviews daily and audits

After sending off the SIR, the facility follows up with an

THE SAFE GUARDING OF VIDEO FOOTAGE RELATING

The facility ensures that video footage is safeguarded as it

The facility ensures that all required and requested

The facility ensures that significant medication errors are

All incident reports are reviewed in morning meeting by the

The campus Risk Manager reviews daily and audits

After sending off the SIR, the facility follows up with an

Improvement, and the CEO receive this information daily for

The facility ensures that video footage is safeguarded as it

The facility ensures that all required and requested

The facility ensures that significant medication errors are

All incident reports are reviewed in morning meeting by the

The campus Risk Manager reviews daily and audits

parties. The audit reported monthly in PI Council.

After sending off the SIR, the facility follows up with an

The facility ensures that video footage is safeguarded as it

The facility ensures that all required and requested

The facility ensures that significant medication errors are

All incident reports are reviewed in morning meeting by the

on an incident report. It is through these incident reports

The campus Risk Manager reviews daily and audits

After sending off the SIR, the facility follows up with an

The facility ensures that video footage is safeguarded as it

The facility ensures that significant medication errors are

All incident reports are reviewed in morning meeting by the

The campus Risk Manager reviews daily and audits

After sending off the SIR, the facility follows up with an

The facility ensures that video footage is safeguarded as it

events causing impact on rights / responsibilities of legal

The facility ensures that significant medication errors are

All incident reports are reviewed in morning meeting by the

The campus Risk Manager reviews daily and audits

After sending off the SIR, the facility follows up with an

The facility ensures that video footage is safeguarded as it

medical attention, elopements, allegations of abuse/neglect,

The facility ensures that significant medication errors are

All incident reports are reviewed in morning meeting by the

The campus Risk Manager reviews daily and audits

After sending off the SIR, the facility follows up with an

The facility ensures that video footage is safeguarded as it

The facility ensures that all required and requested

incidents are completed thoroughly with all required

The facility ensures that significant medication errors are

All incident reports are reviewed in morning meeting by the

The campus Risk Manager reviews daily and audits

After sending off the SIR, the facility follows up with an

The facility ensures that video footage is safeguarded as it

The facility ensures that all required and requested

The facility ensures that significant medication errors are

All incident reports are reviewed in morning meeting by the

The campus Risk Manager reviews daily and audits

After sending off the SIR, the facility follows up with an

The facility ensures that video footage is safeguarded as it

responsible for saving this footage as soon as he/she is

The facility ensures that all required and requested