QA Investigation Results

Pennsylvania Department of Health
ELWYN WINDING WAY
Health Inspection Results
ELWYN WINDING WAY
Health Inspection Results For:


There are  19 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


A focused fundamental recertification survey was conducted on May 24 and 25, 2018. The purpose of this visit was to determine compliance with the requirements of 42 CFR, Part 483, Subpart I Requirements for Intermediate Care Facilities for Individuals with intellectual disabilities. The census at the time of the survey was 5, and the sample consisted of 3 Individuals.









Plan of Correction:




483.410(a)(1) STANDARD
GOVERNING BODY

Name - Component - 00
The governing body must exercise general policy, budget, and operating direction over the facility.




Observations:

Based on facilty record review and documentation, and interview with qualified intellectual disabilities professional and administrative staff, the governing body failed to exercise general direction in the provision of health care services to one of one sample individual with protracted dental needs. This practice is specific to
Individual #1.

Findings include:

A review of the record of Individual #1 was completed on 05/25/2018 between 9 AM and 10:30 AM and revealed the following information:

-A review of a dental report dated 01/04/2017 indicated that the dentist noted
Individual #1 has generalized mild periodontitis, and a chronic cavity in tooth #2.
The #2 tooth was pulled at this appointment. This dental report also identified that this Individual is missing 8 upper teeth and 3 lower teeth. The dentist recommended that Individual #1 return in 12 months.

-Further review of Individual #1's record revealed that no other dental appointments were completed since 01/04/2017. Interview with the facility nurse on 05/25/2018 at approximately 9:30 AM revealed a dental appointment had been scheduled for 01/04/2018, but was not completed as consent had not been secured from Individual's mother. This consent was needed as the dental services used by
Individual #1 require the use of sedation during the procedure.

Interview with the qualified intellectual disabilities professional (QIDP) on 05/25/2018 at approximately 10 AM, revealed that this interviewee had made several attempts to contact Individual #1's mother" who usually gives consent" for this Individual's dental work. This QIDP stated that she had sent out the forms for the mother to sign
however "[Individual #1's] mother never returned them by 01/03/2018".
This interviewee then provided a list of dates when subsequent efforts were made to reach Individual #1's mother to obtain consent for an annual dental visit.
These dates are listed below:
01/31/2018 - Packet of forms were returned to the facility unopened/ These items were sent by certified mail.
02/14/2018 - QIDP attempted telephone contact with Individual #1's mother, but no contact was made.
02/22/2018 - QIDP attempted telephone contact Individual #1's mother, but again no contact was made.

Further interview regarding the above noted phone calls revealed that this interviewee left a voicemail message on 02/22/2018. This interviewee stated she offered to transport the forms to the mother and meet her wherever she wanted to meet in order to get the mother's signature. The mother failed to respond to the voicemail.

Additionally, the QIDP stated:
-That Individual #1 is unable to give informed for consent for dental treatment.
-That [Individual #1's] mother is not legal guardian, but is the designated contact.
-That no further attempts to contact Individual #1's mother occurred after the failed phone contact on 02/22/2018 and that the QIDP then proceeded to follow the agency's policy for when consents for treatment are unobtainable.

3. A reviewof the agency's policy titled, Obtaining Consents dated 02/20/2007 was reviewed on 05/25/2018 at approximately 10:45 AM. This policy states,
"[Agency] will ensure, whenever possible, that informed consent is obtained for each individual for any services /procedures/ treatments for which consent is required."
Under the Section III it is noted that;
" For those individual's who do not have a legal guardian or designated health care proxy and are not functionally competent to provide informed consent the next of kin who is available and willing, will be contacted to provide consents for the individual.
Pursuant to the MH/MR Act of 1966, in the absence of any other appointed decision maker or willing next of kin, the Facility Director or designee becomes the decision maker."

4. Interview with the QIDP on 05/25/2018 at approximately 11:10 AM, revealed that she attempted to seek direction from the Executive Director of Supports for Living, Campus/Community (ED) via email as noted below: :

-02/22/2018 at 12:07 PM to ED from QIDP: "I wanted to get your feedback with regards to an issue we are having getting some consents signed. [Individual #1] needs to be seen at [dental surgeon]. His mother...signs consents for him, however we have been having difficulty getting her to sign the consents. I have reached out to her 3 times and left her messages with regards to getting the consents signed and she has not returned my phone calls. We have sent the consents to her in the mail several times. We have sent the consents by certified mail as well, but she has yet to comply at this point. I told her on the voicemails I left her that I can meet her some place to have her sign the consents if it means he will be seen at dental. At this point, he is out of compliance for dental and I just would like to have your input on how we should proceed with this."

-02/23/2018 at 8:50 AM to QIDP from ED: "Let me check with QI (quality improvement) and possible risk to see what suggested next steps are. Stand by."

-03/15/2018 at 12:38 PM to ED from QIDP: "Any updates on how we should proceed with things with [Individual #1]?"

-04/12/2018 at 3:28 PM to ED from QIDP: "Since we are unable to reach
[Individual #1's] mother to get consent for dental and we are out of compliance at this point. Are you able to sign his consent for [dental surgery]?"

-04/12/2018 at 3:36 PM to QIDP from ED: "I just got an up dated protocol r/t my ability to sign for individuals in this type of situation. I will read through and give you an answer tomorrow."

Continued interview with the QIDP revealed that there were no further emails from the QIDP to the ED nor from the ED to the QIDP. In addition there was no guidance nor direction provided from the ED on how to proceed with dental care for Individual #1 from an agency perspective.

5. A telephone interview with the ED was completed on 05/25/2018 at 11:55 AM. At that time, this interviewee noted that clarification was received on the ability to provide consent for an Individual where consent cannot be obtained from family members,
This interviewee also indicated that said consent will be provided this date in order to receive needed dental services,
































Plan of Correction:

Core Element (CE) #1 Individual #1's consent has been signed by the Executive Director/Supports For Living (ED/SFL) on 5/25/18. All of the other testing/examinations/ paperwork that had expired and needed to be redone (physical exam from the Primary Care Physician to clear for anesthesia, blood work, EKG, etc.) as required by the dental clinic to obtain an appointment have been completed by 6/18/18 and a new dental appointment scheduled by 6/30/18.
Person Responsible: Acting Qualified Intellectual Disability Professional (QIDP)
Completion Date: 6/30/18
CE #2- An audit of the Appointment Trackers on 6/13/18 revealed that no other dental appointments were out of date for the other individuals living in the home.
Person Responsible: Associate Director/Quality Improvement
Completion Date: 6/13/18
CE #3 The requirements for obtaining consents for health care treatments in a timely manner have been modified. The consent form will be mailed to the Substitute Decision Maker (SDM) in a time frame to ensure obtaining the consent at least two weeks prior to the appointment. When it is mailed the QIDP will include a self-addressed stamped envelope to provide ease of return. The QIDP will call the SDM to expect to receive the consent form in the mail. If the consent is not received within a week of the appointment the ED/SFL who is authorized by Act 169 may sign consent for those individuals who do not have a Legal Guardian appointed by the courts. The ED/SFL will require 3 documented attempts to contact the SDM prior to signing the consent in lieu of the SDM. These documented attempts must include at least one attempt to contact the SDM either face to face or via certified mail.
Person Responsible: QIDP and ED/SFL
Completion Date: 6/21/18
CE #4 All upcoming appointments will be reviewed at a monthly meeting (referred to as a POD meeting) attended by the clinical team (Director of Operations, Qualified Intellectual Disability Professional, Psychology Associate, Nurse, Site Supervisor, and Associate Director/Quality Improvement) to ensure timely completion and follow up.
Person Responsible: Director of Operations
Completion Date: 7/31/18 and ongoing
CE #5 The results of the monthly meeting will be submitted by the Director of Operations to the Executive Director/Supports For Living for review and determination of completion of appointments. Failures to complete appointments in a timely manner can result in retraining and/or disciplinary action as needed.
Person Responsible: Director of Operations and Executive Director/Supports For Living
Completion Date: 7/31/18 and ongoing



483.460(f)(2) STANDARD
COMPREHENSIVE DENTAL DIAGNOSTIC SERVICE

Name - Component - 00
Comprehensive dental diagnostic services include periodic examination and diagnosis performed at least annually.



Observations:

Based on record review and interview with administrative staff, the facility failed to provide annual comprehensive dental diagnostic services for one of three sample individuals. This practice is specific to Individual #1.

Findings include:

A review of Individual #1's record on 05/25/2018 from approximately 9 AM to 10:30 AM revealed the following information.

-A review of a dental appointment report dated 01/04 2017 revealed that Individual #1 has generalized mild periodontitis and had a chronic cavity in tooth #2. The #2 tooth was pulled at this appointment. This dental report noted that this individual is missing 8 upper teeth and 3 lower teeth. The dentist recommended that Individual #1 return in 12 months.

-Continued review of this document revealed that as of the date of this survey, 05/25/2018, approximately 16.5 months from the last dental appointment, Individual #1 has not returned to the dentist and no appointment has been made.

Interview with the facility nurse and the qualified intellectual disabilities professional on 05/25/2018 at approximately 10:50 AM, confirmed that Individual #1 has not had a dental appointment since 01/04/2017.




















Plan of Correction:

Core Element (CE) #1 Individual #1's consent has been signed by the Executive Director/Supports For Living (ED/SFL) on 5/25/18. All of the other testing/examinations/ paperwork that had expired and needed to be redone (physical exam from the Primary Care Physician to clear for anesthesia, blood work, EKG, etc.) as required by the dental clinic to obtain an appointment have been completed by 6/18/18 and a new dental appointment scheduled by 6/30/18.
Person Responsible: Acting Qualified Intellectual Disability Professional (QIDP)
Completion Date: 6/30/18
CE #2- An audit of the Appointment Trackers on 6/13/18 revealed that no other dental appointments were out of date for the other individuals living in the home.
Person Responsible: Associate Director/Quality Improvement
Completion Date: 6/13/18
CE #3 The requirements for obtaining consents for health care treatments in a timely manner have been modified. The consent form will be mailed to the Substitute Decision Maker (SDM) in a time frame to ensure obtaining the consent at least two weeks prior to the appointment. When it is mailed the QIDP will include a self-addressed stamped envelope to provide ease of return. The QIDP will call the SDM to expect to receive the consent form in the mail. If the consent is not received within a week of the appointment the ED/SFL who is authorized by Act 169 may sign consent for those individuals who do not have a Legal Guardian appointed by the courts. The ED/SFL will require 3 documented attempts to contact the SDM prior to signing the consent in lieu of the SDM. These documented attempts must include at least one attempt to contact the SDM either face to face or via certified mail.
Person Responsible: QIDP and ED/SFL
Completion Date: 6/21/18
CE #4 All upcoming appointments will be reviewed at a monthly meeting (referred to as a POD meeting) attended by the clinical team (Director of Operations, Qualified Intellectual Disability Professional, Psychology Associate, Nurse, Site Supervisor, and Associate Director/Quality Improvement) to ensure timely completion and follow up.
Person Responsible: Director of Operations
Completion Date: 7/31/18 and ongoing
CE #5 The results of the monthly meeting will be submitted by the Director of Operations to the Executive Director/Supports For Living for review and determination of completion of appointments. Failures to complete appointments in a timely manner can result in retraining and/or disciplinary action as needed.
Person Responsible: Director of Operations and Executive Director/Supports For Living
Completion Date: 7/31/18 and ongoing