QA Investigation Results

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


There are  20 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 15 and 16, 2019. The purpose of this visit was to determine compliance with the requirements of 42 CFR, Part 483, Subpart I regulations for Intermediate Care Facilities for Individuals with intellectual disabilities. The census at the time of the survey was four, and the sample consisted of four Individuals.










Plan of Correction:




483.440(c)(2) STANDARD
INDIVIDUAL PROGRAM PLAN

Name - Component - 00
Participation by the client, his or her parent (if the client is a minor), or the client's legal guardian is required unless the participation is unobtainable or inappropriate.



Observations:


Based on record review and interview with administrative staff, the facility failed to ensure that the an Individual was a participant in interdisciplinary team meetings for two of four sample Individuals. This practice is specific to Individuals #1 and #2.

Findings include:

Individual #1
A review of Individual #1's record was completed on 05/16/2019 from approximately 9:15 AM until 11:30 AM. and revealed the following:

A review of the the Individual Program Plan (IPP) meeting report revealed a document titled, Interdisciplinary Team Attendance Sheet; Quarterly/Annual, dated 01/14/2019. This document revealed the following sections:

Interdisciplinary Team members in attendance at the review meeting. In the section there is a space for the individual team member to write their signature and print their name/title. Upon further review of this section it was noted that Individual #1 was not in attendance at this meeting.

Further review of this same document revealed the following two sections:
-A section titled, "If Individual not in attendance, why?"
-A section titled, "Plan reviewed with individual if not in attendance on ____"

Continued review of both of these sections revealed that there was no information documented as to why Individual #2 failed to attend her annual planning meeting.

Individual #2
A review of Individual #2's record was completed on 05/16/2019 from approximately 9:15 AM until 11:30 AM, and revealed the following:

In a review of the the Individual Program Plan (IPP) meeting report revealed a document titled, Interdisciplinary Team Attendance Sheet; Quarterly/Annual, dated 06/21/2018. This document revealed the following sections:

Interdisciplinary Team members in attendance at the review meeting. In the section there is a space for the individual team member to write their signature and print their name/title. Upon further review of this section it was noted that Individual #2 was not in attendance at this meeting.

Further review of this same document revealed the following two sections:
-A section titled, "If Individual not in attendance, why?"
-A section titled, "Plan reviewed with individual if not in attendance on ____"

Continued review of both of these sections revealed that there was no information documented as to why Individual #2 failed to attend her annual planning meeting.

Interview with the program director on 05/16/2019 at approximately 11:15 AM, revealed that she could not provide any evidence that Individuals #1 and #2 had attended their respective annual planning meetings.























































Plan of Correction:

Critical Element (CE) #1 For Individuals #1 and #2, any Annual IPP (Individual Program Plan) Reviews and/or Special Team Meetings (STMs) conducted for them, that they did not sign their respective participation in the past year, the QIDP (Qualified Intellectual Disability Professional) will review the contents of the meeting with the Individual. The date of the review of the contents will be documented on the original IDT (Interdisciplinary Team) Attendance Sheet, as well as the name of the QIDP who reviewed it with the individual and the reason why it was necessary to do so. Then, the respective individual will sign the IDT Attendance Sheet in the section for the signatures of those who did not attend the meeting but approve the plan. The original IDT Attendance Sheet will be filed in the individuals file with the corresponding IPP or STM. A copy of the completed IDT Attendance Sheets will be reviewed for completion by the Program Director and forwarded to the Quality Improvement Department for final review.

Person Responsible: QIDP, Program Director and Quality Improvement Specialist
Date of Completion: 6/17/19

CE #2 The same corrective action noted in CE #1 will be done for the other individuals of the home. All the records will be reviewed and any Annual IPP (Individual Program Plan) Reviews and/or Special Team Meetings (STMs) conducted for the other individuals that are identified that the other individuals also did not sign their respective participation in the past year, the QIDP (Qualified Intellectual Disability Professional) will review the contents of the meeting with the Individual. The date of the review of the contents will be documented on the original IDT (Interdisciplinary Team) Attendance Sheet, as well as the name of the QIDP who reviewed it with the individual and the reason why it was necessary to do so. Then, the respective individual will sign the IDT Attendance Sheet in the section for the signatures of those who did not attend the meeting but approve the plan. The original IDT Attendance Sheet will be filed in the individuals file with the corresponding IPP or STM. A copy of the completed IDT Attendance Sheets will be reviewed for completion by the Program Director and forwarded to the Quality Improvement Department for final review.

Person Responsible: QIDP, Program Director and Quality Improvement Specialist
Date of Completion : 6/17/19

CE #3 a. The QIDP, Program Director and the Director of Operations were sent an email on 5/28/19 with the Policy and Procedure (P/P) for the IDT Attendance Sheet reminding them to follow the correct procedures to document Individual attendance/participation in Team Meetings.
b. The Psychology Associate/Clinician was trained during the 6/6/19 Human Rights Committee (HRC) meeting. A follow up email to the training (with attachments of the P/P and the form for the IDT Attendance Sheet) was sent to all the Psychology Associates/Clinicians on 6/6/19 by the HRC Chair.
c. All the QIDP's, Program Directors, Associate Director and Director of Operations will be retrained on the procedures to ensure each individual attends/participates in his/her ongoing Team meetings.

Person Responsible: Associate Director of Quality Improvement and Program Director
Date of Completion: 6/20/19 and ongoing

CE #4 - Documentation that the Plan was reviewed with the individual's signature will be placed in the respective individual's file and a copy submitted to the Program Director to ensure completion. Additionally, when the Record Audit is conducted, the individual's participation in the Team meetings is audited and corrected if needed.

Person Responsible: Program Director and Director of Operations
Date of Completion: 6/30/19 and ongoing

CE #5 The Director of Operations will ensure that follow up is being managed by the Program Director and QIDP. Failure to ensure correction can result in additional training and/or disciplinary action as appropriate.
Person Responsible: Director of Operations
Date of Completion: 6/30/19 and ongoing



483.470(i)(1) STANDARD
EVACUATION DRILLS

Name - Component - 00
The facility must hold evacuation drills at least quarterly for each shift of personnel.



Observations:


Based on a review of facility documentation and interview with facility staff, the facility failed to hold evacuation drills at least quarterly for each shift of personnel.

Findings include:

A review of fire drill reports for the period from April 2018 to March 2019 was completed on 05/16/2019 between 9:30 AM and 10:15 AM. This review revealed that there were no evacuation drills conducted for the second shift of personnel during the second and fourth calendar quarters of 2018.

Interview with the program director on 05/15/2019 from approximately 10:00 AM to 10:15 AM confirmed that there was no fire drills conducted during second shift of personnel for the two calendar quarters noted above.









Plan of Correction:

CE #1 A Policy and Procedure for Fire Safety Training has been developed as of 6/18/19. For Individuals #1, #2, #3 and #4 training on what to do during fire drills will be completed by 6/28/19. Going forward, this training will be conducted for all new admissions to the home and annually thereafter. The training content will include: general fire safety, evacuation procedures, responsibilities and the designated meeting place.
Person Responsible: QIDP
Date of Completion: 6/28/19 and ongoing

CE #2 Since CE #1 involves all the residents of the home, CE #2 is the same. A Policy and Procedure for Fire Safety Training has been developed as of 6/1819. For Individuals #1, #2, #3 and #4 training on what to do during fire drills will be completed by 6/28/19. Going forward, this training will be conducted for all new admissions to the home and annually thereafter. The training content will include: general fire safety, evacuation procedures, responsibilities and the designated meeting place.
Person Responsible: QIDP
Date of Completion: 6/28/19 and ongoing
CE#3 a. The Quality Improvement Specialist will meet with the Program Director and Director of Operations to inservice the criteria for fire drills for each shift and the need to vary drill times throughout first, second and third shifts. Training will be documented and submitted to the Director of Quality Improvement.
b. Fire drills will be conducted by the Site Supervisor or designee on a quarterly basis for each shift, within the first two weeks of each month. The facility will revise the Fire Drill Schedules going forward to ensure the drills are held under varied times for the first, second and third shifts each calendar quarter. The Site Supervisor will fax a copy of the completed fire drill report to the Program Director immediately following the completion of the fire drill for review. If corrective action is warranted, the Site Supervisor will address the issue and/or conduct a second fire drill within seven calendar days. A copy of the second fire drill will be faxed to the Program Director for review immediately following the completion of the fire drill. If corrective action is again warranted, the Site Supervisor will address the issue and/or conduct a third fire drill within seven calendar days.
c. The Program Director will be responsible for the monitoring of evacuation drills within 3 days of receipt of the completed fire drill forms to ensure that the drills are conducted under varied conditions by alternating time periods in which the drill is conducted on first, second and third shifts.
Person Responsible: Site Supervisor, Program Director, Quality Improvement Specialist
Date of Completion: 8/30/19 and ongoing

CE #4 A monthly meeting is held with the clinical/managerial team (QIDP, Site Supervisor, Nurse, Clinician, Program Director, Director of Operations and Quality Improvement Specialist) for the community based ICF homes. Added to the monthly agenda, will be a review of the Fire Drills conducted since the previous meeting to ensure that any issues regarding conducting a drill on each shift at varied times for each quarter are completed as required.

Person Responsible: Director of Operations
Date of Completion: 8/30/19 and ongoing

CE #5 The Director of Operations will ensure that Fire Drills are covered in the monthly agenda and address any issues as needed. Failure to ensure the drills are held each shift per quarter can result in additional training and/or disciplinary action as needed.

Person Responsible: Director of Operations
Date of Completion: 8/30/19 and ongoing



483.470(i)(2)(iii) STANDARD
EVACUATION DRILLS

Name - Component - 00
The facility must file a report and evaluation on each evacuation drill.



Observations:


Based on a review of facility documentation and interview with administrative staff,
the facility failed to file a report and evaluation on each evacuation drill conducted at the facility.

Findings include:

A review of fire evacuation drills completed for the period from April 2018 through March, 2019 revealed that although documentation of each drill was maintained, there was no evidence that the facility had evaluated the results of these drills specific to the condition of route of evacuation. Examples of this practice are as follows:

-May 10, 2018 at 2:00 AM:
Individuals #1, 2, 4 asleep, third shift of personnel:
Designated area of fire was listed as the bedroom, specific bedroom not identified on this report. The bedrooms within this residence are located along a common hallway that leads to the living room area and front door, as well as an exit door located at the other end of this hallway that also exits to the outdoors. This report also states under the section titled, Discussion after drill, "Importance of fire drill, safety precautions."

-May 13, 2018 at 2:30 AM, third shift of personnel:
Individuals #1, 2, 3, 4 were asleep at the time of this evacuation drill. The designated area of fire was listed as the bedroom (not identified) and all Individuals exited through the front door of the residence.

-August 17, 2018 at 2:45 AM, third shift of personnel:
Individuals #1, 2, 3, 4 were asleep at the time of this evacuation drill. The designated area of fire was listed as the bathroom. Documentation of this evacuation drill indicates that all individuals exited directly in front of the designated fire area, and exited through the front door.

-October 10, 2018 at 7:42 AM, first shift of personnel:
Individuals #1, 2, 3, 4 were awake at the time of the evacuation drill. The designated area of fire was listed as the bedroom, specific bedroom not identified on this report. Documentation of this evacuation drill indicates that Individuals exited through the hallway adjacent to all bedroom areas, and exited through the front door.

-February 10, 2019 at 6:00 AM, third shift of personnel:
Individuals #1, 2, 3, 4 were asleep at the time of this evacuation drill. The designated area of fire was listed as the bathroom. Documentation of this evacuation drill reflects that all individuals passed directly in front of the designated fire, and exited the residence through the front door.

Upon further review, there was no evidence that the facility evaluated the evacuation drills to identify problems in order to develop corrective action to address these problems.

Interview with the program director on 05/16/2019 between 10:00 AM and 10:15 AM, acknowledged that the facility does not evaluate the evacuation reports to identify problems regarding the egress utilized during the evacuation drills.










Plan of Correction:

CE #1 - A Policy and Procedure for Fire Safety Training has been developed as of 6/18/19. For Individuals #1, #2, #3 and #4 training on what to do during fire drills will be completed by 6/28/19. Going forward, this training will be conducted for all new admissions to the home and annually thereafter. The training content will include: general fire safety, evacuation procedures (to include the best exit to use based on the location of any given potential fire and where the individual is located in the home at the time of the potential fire), responsibilities and the designated meeting place.
Person Responsible: QIDP
Date of Completion: 6/28/19 and ongoing

CE #2 - Since CE #1 involves all the residents of the home, CE #2 is the same. For Individuals #1, #2, #3 and #4 training on what to do during fire drills will be completed by 6/28/19. Going forward, this training will be conducted for all new admissions to the home and annually thereafter. The training content will include: general fire safety, evacuation procedures (to include the best exit to use based on the location of any given potential fire and where the individual is located in the home at the time of the potential fire), responsibilities and the designated meeting place.
Person Responsible: QIDP
Date of Completion: 6/28/19 and ongoing

CE #3 -
a. The Quality Improvement Specialist will meet with the Program Director and Director of Operations to inservice the criteria for documenting the area of the fire during each drill and the need to exit in the most expeditious and safe manner to avoid the fire based on where each individual is located in the home at the time of the drill. Training will be documented and submitted to the Director of Quality Improvement.

b. The facility will revise the Fire Drill Schedule to be more specific about the fire locations for each drill and indicate the best (expeditious and safe) exits based on where any given individual is located within the home. The Site Supervisor or designee will conduct the drills and will fax a copy of the completed fire drill report to the Program Director immediately following the completion of the fire drill for review. If corrective action is warranted, the Site Supervisor will address the issue and/or conduct a second fire drill within seven calendar days. A copy of the second fire drill will be faxed to the Program Director for review immediately following the completion of the fire drill. If corrective action is again warranted, the Site Supervisor will address the issue and/or conduct a third fire drill within seven calendar days.
c. The Program Director will be responsible for the monitoring of evacuation drills within 3 days of receipt of the completed fire drill form to ensure that the drills indicate the exact location of the fire and that everyone evacuated in the most expeditious and safe manner.
Person Responsible: Site Supervisor, Program Director, Quality Improvement Specialist
Date of Completion: 8/30/19 and ongoing

CE #4 A monthly meeting is held with the clinical/managerial team (QIDP, Site Supervisor, Nurse, Clinician, Program Director, Director of Operations and Quality Improvement Specialist) for the community based ICF homes. Added to the monthly agenda, will be a review of the Fire Drills conducted since the previous meeting to ensure that any issues regarding conducting a drill in regards to fire location and exit strategy is addressed.

Person Responsible: Director of Operations
Date of Completion: 8/30/19 and ongoing

CE #5 The Director of Operations will ensure that Fire Drills are covered in the monthly agenda and address any issues as needed. Failure to ensure the drill reports reflect the exact fire location and the most expeditious and safe exit strategy can result in additional training and/or disciplinary action as needed.

Person Responsible: Director of Operations
Date of Completion: 8/30/19 and ongoing