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The Program Coordinator will train the Supervisor who, in turn, will train all Direct Support Professional staff on the importance of keeping all drugs and biologicals locked except when being prepared for administration. Training will include the importance of not walking away from unlocked medication. Staff will be trained by May 15, 2023; the Program Director will sign and date the Supervisor's training to ensure completion, and the Program Coordinator will do the same for Direct Support Professional staff. The Supervisor will ensure all DSP staff are trained by comparing completed training records with the staff schedule. Training records will be maintained in the personnel files.

A supervisory team member will conduct unannounced observations, at varied medication administration times, to ensure that all drugs and biologicals locked except when being prepared for administration, and that staff do not walk away from unlocked medications. Observations will be recorded on a tracking grid developed by the Program Director. The tracking grid will specify whether the drugs and biologicals are locked except when being prepared for administration, and whether or not staff walk away from unlocked medication. Observations will begin by May 15, 2023 and all DSP staff who work in the home will have at least two checks completed during their shift by June 1, 2023. If staff does not ensure all drugs and biologicals are locked except when being prepared for administration, the staff member making the error will continue to be observed at least two times every two weeks until there are three successful observations, defined as keeping all drugs and biologicals locked except when being prepared for administration. Documentation of these observations will be on or attached to the tracking grid developed by the Program Director.

After two successful observations the monitoring will be faded to one additional time by June 15, 2023, then two times per year and conducted during the time of each staff member's semi-annual medication administration training. If staff does not ensure all drugs and biologicals are locked except when being prepared for administration during their third observation, the staff member making the error will continue to be observed at least two times every two weeks until there are three successful observations, defined as keeping all drugs and biologicals locked except when being prepared for administration.

Observations through June will be recorded on the tracking grid and the bi-annual observations will be documented on a form designated by the Medication Administration Training. Medication Administration Training stresses the importance of ensuring all drugs and biologicals are locked except when being prepared for administration. The Program Coordinator will review to ensure compliance for the two months, and document her review by signing and dating the tracking grid.

The Learning Program Assistant will track annual training requirements to ensure all requirements are met for all staff who administer medication and communicate this information on a regular and on-going basis to the Administrative Coordinator and DSP staff via e-mail. As well, the Learning Program Assistant will maintain this information on a chart located on the internet which all Devereux Pa Adult Services staff has access to.

Failure to follow the steps outlined in this plan of correction will lead to re-training and the policy for progressive discipline will take effect.

The Program Coordinator will train the Supervisor to hold evacuation drills at least quarterly for each shift of personnel. Training will focus on ensuring evacuation drills are held on each of the three shifts each quarter of the calendar year, including 3rd shift. Training will include a review of the Fire Drill Schedule for 2023, developed by the Program Director, to assist in assuring compliance. Training will take place by May 15, 2023 and the Program Director will sign and date the training to assure completion. Training records will be maintained in the personnel files.

The Program Coordinator and will monitor monthly fire drills on an ongoing basis to ensure drills are held at least quarterly for each shift of personnel, according to the schedule.

Immediately following the drill, the Program Supervisor will send a text message the Program Coordinator confirmation the drill was completed, and the time it took to evacuate the home. Within 72 hours of a fire drill, the Supervisor will scan and email the designated documentation paperwork to the Quality Management Specialist, Program Coordinator, and Program Director who will review fire drills and monitor to ensure they are being done as per the schedule. If the drill is not preformed according to the schedule, another drill will be held that quarter at the specified time, as per the schedule. For the next 6 months, the Coordinator, or designee, will respond to the e-mail documenting her review, and documenting whether or not another drill needs to be conducted. Fire drill reports will be maintained at the facility. The Supervisor will print e-mail threads and place them in the Plan of Correction binder.

If there are no problems noted, moving forward the Coordinator will still monitor the drills to assure drills are done at least quarterly for each shift of personnel however the Coordinator may only respond if problems are noted. The Quality Management Specialist will oversee reviewing and signing the fire drill report and providing feedback if corrective actions are needed. The Quality Management Specialist may only respond if problems are noted.

Failure to follow the steps outlined in this plan of correction will lead to re-training and the policy for progressive discipline will be take effect.

The Director of Nursing will train the Health Services Coordinator on the importance of assuring that that each client receives a nourishing, well-balanced diet including modified and specially prescribed diets. Training will include the importance of scanning all verbal orders to the pharmacy, so they can be updated on the standing Physician's Orders for Individual #1 and all individuals. Training will be completed by April 30, 2023. The Program Director, or designee, will sign and date the training record to assure completion. The training records will be maintained in the personnel file and the Plan of Correction Binder in the nursing department.
The Dietitian will also review the physician orders for all of the individuals at Country Club by April 30, 2023 and each month for the next six months to double check that the change from her previous recommendations were made, and reflect on the physician orders. If errors are found, the Dietitian will notify the Interdisciplinary Team, including the Health Service Coordinator immediately via email so the error can be resolved. Both the Health Services Coordinator and the Dietitian will DocuSign an audit form that the Director of Nursing will send them at the end of the month confirming that the diets on the physician orders were checked against the current orders and that they do match what they are being served.
Diet changes can occur at any time as recommended by the Dietitian, a speech language pathologist, specialty provider or the primary care physician. The Health Services Coordinator will obtain a verbal order from the individual's PCP following a recommended diet change. The nurse sends the order to the pharmacy and to the Dietitian, and verbal order becomes part of the standing physician's orders, reflected the next time the orders are printed by the pharmacy.

Each month, the nurse reconciles and cross checks the orders from the past month to the current month. Any discrepancies must immediately be resolved with an order from the PCP and the communication with the pharmacy. An email should be sent out to update the Interdisciplinary team and vocational program where food may be served.

Compliance will be monitored as per the training, monthly, for the next six months. The Director of Nursing will assure the Health Services Coordinator obtains a physician order for all new diet changes and it is communicated to the Interdisciplinary Team, the physician order, and the diet change form is completed. If an order is not provided, the Director of Nursing will immediately contact the Health Services Coordinator and the Dietitian to request that one be obtained. If there are no errors or discrepancies for six months, meaning the diet orders match the physician orders correctly the Director of Nursing will respond to the emails about diet changes for an additional 1 month. The emails will be maintained in a file created by the Director of Nursing for ongoing reference. If there continue to be no errors, meaning physician orders match the diet instructions and the diet that is being served the auditing and email responses will cease but the Director of Nursing is expected to regularly monitor related communication about diets to ensure compliance.

The Program Coordinator will train the Program Supervisor who, in turn, will train the
Direct Support Professional Staff on the importance of ensuring each client receives a nourishing, well-balanced diet including modified and specially prescribed diets. Training will review the current prescribed diet for individual #1 and all individuals. Training will focus on, but not be limited to, assuring prescribed diets are following all times by providing prescribed liquid quantity, such as Individual #1's need to have beverages given 4oz at a time. Training will be completed by May 15, 2023. Staff will be trained by May 15, 2023; the Program Director will sign and date the Supervisor's training to ensure completion, and the Program Coordinator will do the same for Direct Support Professional staff. The Supervisor will ensure all DSP staff are trained by comparing completed training records with the staff schedule. Training records will be maintained in the personnel files.

A supervisory staff will make unannounced observations of meal times, snack times, and medication administration times to ensure all individuals are consuming food and beverages according to their prescribed diets. Observations will begin by May 15, 2023, and all DSP staff in the home will be observed at least two times by June 1, 2023. If staff does not provide the correct prescribed diet, the staff member making the error will continue to be observed at least two times every two weeks until there are three successful observations, defined by assuring that each individual receives a nourishing, well-balanced diet including modified and specially prescribed diets during meals. Documentation of these observations will be on or attached to the tracking grid developed by the Program Director.

After two successful observations the monitoring will be faded to one additional time by June 2023. If staff does not ensure modified and specially prescribed diets are followed, the staff member making the error will continue to be observed at least two times every two weeks until there are three successful observations, defined by assuring that each individual receives a nourishing, well-balanced diet including modified and specially prescribed diets. Documentation of observations through June will be maintained on the tracking grid, and documentation of any additional observations will be on or attached to the tracking grid.

Moving forward, the supervisory team will complete at least one formal (documented on a specified form) and one informal meal observations per month in the home and follow the process outlined above. The Program Coordinator will oversee and maintain the observation schedule and ensure feedback is given immediately to the staff, and to the supervisor during monthly supervision meetings with the Coordinator. Documentation of the observations will be maintained in a specified binder at the facility.

Failure to follow the steps outlined in this plan of correction will lead to re-training and the policy for progressive discipline will take effect.