QA Investigation Results

Pennsylvania Department of Health
DEVEREUX PA ADULT SERVICES - FAREFORTH
Health Inspection Results
DEVEREUX PA ADULT SERVICES - FAREFORTH
Health Inspection Results For:


There are  23 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:

A monitoring survey was conducted on January 7-8, 2019, to determine compliance with the requirements of 42 CFR Part 483, Subpart I Requirements for Intermediate Care Facilities. The census during the survey was seven. Three deficiencies were identified.








Plan of Correction:




483.420(a)(7) STANDARD
PROTECTION OF CLIENTS RIGHTS

Name - Component - 00
The facility must ensure the rights of all clients. Therefore, the facility must ensure privacy during treatment and care of personal needs.



Observations:

Based on observation and staff interview, it was determined that the facility failed to ensure privacy was provided during treatments. This was noted for the only individual in the home who received a treatment during the morning medication administration (Individual #5). The findings included:

Medication administration was observed on January 8, 2019, from 7:16 AM to 8:35 AM.

A) Individual #5 was observed to receive his medications while seated at the dining room table at 8:10 AM. This individual was handed Flonase nasal spray and verbally prompted by staff to self-administer this treatment. Individual #5 proceeded to spray two squirts into each nostril. During the administration of the nasal spray, five of the six other individuals in the home were also seated at the dining room table in clear view of Individual #5.

B) The staff administering medications (SAM) was interviewed on January 8, 2019, at 8:43 AM. The SAM confirmed that Individual #5 was not provided with privacy during the administration of the nasal spray.












Plan of Correction:

130 The facility must ensure the rights of all clients. Therefore, the facility must ensure privacy during treatments and care of personal needs.

The QIDP Supervisor will train all Direct Support Professional (DSP) staff on the importance of ensuring the rights of all clients by ensuring privacy during treatments and care of personal needs. The training will focus on, but not be limited to, ensuring privacy during treatments, which includes administering, and assisting individuals with administering, all medically related treatments, such as nasal spray in a private area. The training will take place by February 7, 2019. The QIDP will ensure all DSP staff are trained by comparing completed training records with the staff schedule for the month of March to ensure all staff who work in the program are trained. The QIDP Coordinator will sign and date the training to ensure completion. Training records will be maintained in the personnel files.

To ensure compliance, a supervisory staff will make unannounced observations to ensure Individual #5, and all Individuals, receive privacy during treatment and care of personal needs. These monitoring's will begin February 7, 2019 and all DSP staff in the home will be observed at least two times by March 1, 2019. If staff does not ensure privacy during personal care, 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 ensuring privacy during treatments. Documentation of all observations will be on a tracking grid and will specify whether or not privacy was given.

The QIDP Coordinator will ensure all DSP staff of the home is observed by comparing the tracking grid with the staff schedule. The QIDP Coordinator will review, initial, and date all observations on the tracking grid to ensure compliance. The tracking grid will be maintained in the plan of correction binder.

After two successful observations the monitoring will be faded to one additional time in the month in March, then two times per year and conducted during the time of each staff member's semi-annual medication administration training. Observations in February and March 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 specifies the importance of administering treatments in private. If an error is noted by the certified medication observer, and privacy not maintained, the staff member will receive corrective action and will continue to be observed until three additional, successful, medication administration sessions are observed, which includes providing privacy during treatment.

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 Program Coordinator 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.



483.460(k)(1) STANDARD
DRUG ADMINISTRATION

Name - Component - 00
The system for drug administration must assure that all drugs are administered in compliance with the physician's orders.



Observations:

Based on observation, record review, and staff interview, it was determined that the facility failed to ensure medications were administered in compliance with physician's orders. This was noted for all seven individuals in the home (Individuals #1, #2, #3, #4, #5, #6, and #7). The findings included:

Medication administration was observed on January 8, 2019, from 7:16 AM to 8:35 AM. Physician's orders for all seven individuals were reviewed immediately following the administration. The breakfast meal was observed from 7:10 AM to 7:35 AM.

A) Individual #1

Individual #1 received her medications, which included Vitamin D3, 1000 units (U), one tablet daily, at 7:39 AM. Review of signed physician's orders, dated September 5, 2018, revealed the orders did not include the medication Vitamin D3, 1000 U. Upon surveyor inquiry, the nurse provided a verbal order, obtained from her computer, for the medication, Vitamin D3, 1000 U.

Further review of these physician's orders revealed that they were "90-day orders". There were no current signed physician's orders in Individual #1's record.

The facility nurse and program director (PD) were interviewed on January 8, 2019, at 9:57 AM. The nurse and PD confirmed there was no signed order in Individual #1's record for the medication Vitamin D3, 1000 U. In addition, the nurse and PD confirmed that Individual #1 received all her morning medications without current signed physician's orders.

B) Individual #4

Observation of the morning meal on January 8, 2019, revealed that Individual #4 started to eat his meal at 7:10 AM. This individual received his medications, which included Proscar five milligrams (mgs), at 8:35 AM. Review of signed physician's orders, dated September 5, 2018, revealed that this medication was prescribed "30 minutes before the first meal of the day".

The staff administering medication (SAM) was interviewed on January 8, 2019, at 8:44 AM. The SAM confirmed that the medication, Proscar, was prescribed to be given before breakfast, and Individual #1 received it after breakfast.

Further review of these physician's orders revealed that they were "90-day orders". There were no current signed physician's orders in Individual #4's record.

The facility nurse and PD were interviewed on January 8, 2019, at 9:57 AM. The nurse and PD confirmed that Individual #4 received all his morning medications without current signed physician's orders.

C) Individual #5

Individual #5 received his medications at 8:10 AM. Review of this individual's signed physician's orders, dated September 5, 2018, revealed he was prescribed Protonix 40 mgs, one tablet twice daily, and Aspirin 325 mgs, one tablet daily. Individual #5 was not observed to receive these medications.

Further review of these physician's orders revealed that they were "90-day orders". There were no current signed physician's orders in Individual #5's record.

The facility nurse and PD were interviewed on January 8, 2019, at 10:05 AM. The nurse and PD acknowledged that Individual #5 did not receive the medications Protonix and Aspirin as prescribed. In addition, the nurse and PD confirmed that Individual #5 received all his morning medications without current signed physician's orders.

D) Individual #6

Individual #6 received her medications at 7:57 AM. Review of signed physician's orders, dated September 5, 2018, revealed this individual was prescribed Peridex mouthwash, "rinse mouth with half ounce twice daily after breakfast and before bedtime". Individual #6 was not observed to use her Peridex mouthwash after breakfast.

Further review of these physician's orders revealed that they were "90-day orders". There were no current signed physician's orders in Individual #6's record.

The facility nurse and PD were interviewed on January 8, 2019, at 9:59 AM. The nurse and PD acknowledged that Individual #6 did not receive the Peridex mouthwash as prescribed. In addition, the nurse and PD confirmed that Individual #6 received all her morning medications without current signed physician's orders.

E) Individual #2

Individual #2 received her medications at 7:49 AM. Review of Individual #2's physician's orders revealed they were signed on September 5, 2018. Further review of these physician's orders revealed that they were "90-day orders". There were no current signed physician's orders in Individual #2's record.

The nurse and PD were interviewed on January 8, 2019, at 9:57 AM. The nurse and PD confirmed that Individual #2 received all her morning medications without current signed physician's orders.

F) Individual #3

Individual #3 received her medications at 7:28 AM. Review of Individual #3's physician's orders revealed they were signed on July 25, 2018. Further review of these physician's orders revealed that they were "90-day orders". There were no current signed physician's orders in Individual #3's record.

The nurse and PD were interviewed on January 8, 2019, at 9:57 AM. The nurse and PD confirmed that Individual #3 received all her morning medications without current signed physician's orders.

G) Individual #7

Individual #7 received her medications at 7:16 AM. Review of Individual #7's physician's orders revealed they were signed on September 5, 2018. Further review of these physician's orders revealed that they were "90-day orders". There were no current signed physician's orders in Individual #7's record.

The nurse and PD were interviewed on January 8, 2019, at 9:57 AM. The nurse and PD confirmed that Individual #7 received all her morning medications without current signed physician's orders.












Plan of Correction:

368 The system for drug administration must assure that all drugs are administered in compliance with physician's orders.

Following the medication errors for individual #4, #5 and #6 the Health Services Coordinator was contacted immediately, who in turn contacted the Primary Care Physician immediately for orders as to how to proceed. The staff member making the error was identified, and received training and disciplinary action according to agency policy.

Individual #1's verbal order for vitamin D3, 1000 units (U), one tablet daily was placed in her record by the Health Services Coordinator at the time of the survey.

The Director of Nursing will train all Health Services Coordinators on the importance of ensuring that that all drugs are administered in compliance with physician's orders. The training will include, but not be limited to, ensuring that all physician orders are signed prior to their expiration date, and placed in the individual's record. This training will be complete by February 15, 2019 and signed and dated by the Program Director to ensure completion. The Director of Nursing will ensure all Health Services Coordinators are trained by comparing the completed training sheets to t staff schedule to ensure completion. Training records will be maintained by the Human Resources Department.

The Health Services Coordinator completed an audit on January 11, 2019. The primary care physicians discontinued "ninety day orders" for Individuals #1, #2, #3, #4, #5, #6, and #7 and indicated, by signing new orders, that they are now valid for 365 days on 01/23/2019. The Health Services Coordinator will complete monthly audits of physician orders so that they will be able to identify any change in orders.

The QIDP will train all Direct Support Professional (DSP) staff on the importance of ensuring that that all drugs are administered in compliance with physician's orders. The training will include, but not be limited to, ensuring that all medications prescribed are administered, and special instructions for time are followed. This training will be complete by February 7, 2019 and signed and dated by the QIDP Coordinator to ensure completion. The QIDP will ensure all staff are trained by comparing the completed training sheets to the staff schedule to ensure completion. Training records will be maintained by the Human Resources Department.

A supervisory staff member will conduct unannounced observations, at varied medication administration times, to ensure that all medication is administered in compliance with physician's orders which includes ensuring that all medications prescribed are administered, and special instructions for time are followed. Observations will be recorded on tracking grid developed by the Program Director and will specify whether the medication is administered in compliance with physician's orders. These monitoring's will begin February 7, 2019 and all staff will be observed at least three times by March 1, 2019. If staff does not ensure medication is administered in compliance with physician's orders, the staff member making the error will continue to be observed at least two times every week until there are four successful observations, defined by administering medication according to physician's orders. Documentation of all observations will be on a tracking grid. The QIDP Coordinator will review, sign, and date the tracking grid by March 1, 2019 to ensure compliance. The QIDP will ensure all staff is observed by comparing completed observation forms with the staff schedule.

After three successful observations the monitoring will be faded to two additional times in the month of March, then two times per year and conducted during the time of each staff member's semi-annual medication administration training as medication administration. Observations in February and March 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 administering all medications in compliance with physician's orders. If an error is noted the staff member will receive corrective action and will continue to be observed until three additional, successful, medication administration sessions are observed, as defined above.

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.



483.480(a)(1) STANDARD
FOOD AND NUTRITION SERVICES

Name - Component - 00
Each client must receive a nourishing, well-balanced diet including modified and specially-prescribed diets.



Observations:

Based on observation, record review, and staff interview, it was determined that the facility failed to ensure specially prescribed diets were provided. This was noted for three of the seven individuals present during the survey (Individuals #1, #4, and #5). The findings included:

A) Individual #4

The dinner meal was observed on January 7, 2019, between 5:15 PM and 6:00 PM. The observation revealed that Individual #4 consumed two glasses of juice, approximately eight ounces each. This individual then removed himself from the dining room table for a period. Staff prepared a lunchmeat sandwich as an alternative meal and asked Individual #4 to return to the table. This individual refused the sandwich and stated that he wanted ice cream. Staff provided Individual #4 with a "Magic Cup". (This is a frozen supplement that contains nine milligrams of protein). Individual #4 ate the "Magic Cup" for his dinner meal and left the dining room table.

The morning meal was observed on January 8, 2019, between 7:10 AM and 7:35 AM. The observation revealed that Individual #4 ate approximately one cup of Cheerios with one cup of milk. This individual poured a full cup of coffee, approximately eight ounces. After taking a few sips, Individual #4 re-filled his cup of coffee to the rim with approximately another two ounces. This individual was provided with an Ensure drink which he consumed.

Review of Individual #4's most recent signed physician's orders dated September 5, 2018, revealed the following: Fluid restriction of 1500 milliters per day; encourage fluid restriction to eight ounces per meal; give one Ensure pudding at breakfast, lunch, afternoon snack, and dinner; Magic cup- take one cup as bedtime snack.

Review of the fluid restriction documentation revealed that each day was divided into blocks of time, which staff were to document if Individual #4 consumed eight ounces of fluid. Staff are to indicate "yes" or "no". Review of documentation for January 7, 2019, evening meal revealed that a "check mark" was placed in "yes". There was no documentation that this individual consumed an extra eight ounces during the dinner meal.

The program director (PD) was interviewed on January 8, 2019, at 9:30 AM. The PD confirmed that Individual #4 did not receive his specially prescribed diet. In addition, the PD acknowledged that the fluid restriction documentation did not reflect the actual consumption of fluid.

B) Individual #5

The morning meal was observed on January 8, 2019, between 7:10 AM and 7:35 AM. Staff poured a glass of water and a glass of juice for Individual #5 and added thickener to them. Staff stirred the liquids after several minutes, but the fluids had clumps at the bottom of the glasses. This individual poured his own cup of coffee from a pitcher. Staff did not add thickener to the coffee. After Individual #5 drank the last few sips of coffee, he coughed a few times. Staff asked if he was "Okay". At 7:45 AM, this individual coughed another five times.

Review of Individual #5's signed physician's orders, dated September 5, 2018, revealed the following: nectar thick liquids; aspiration precautions; encourage hydration.

The PD was interviewed on January 8, 2019, at 9:35 AM. The PD acknowledged that Individual #5's prescribed diet was not followed by drinking his morning coffee without the benefit of thickener in it.

C) Individual #1

The morning meal was observed on January 8, 2019, between 7:10 AM and 7:35 AM. This individual had a water bottle with a straw built-in the lid, at her place setting. Individual #1 poured herself a cup of coffee and added sweetener to it. This individual drank both beverages without issue.

Review of Individual #1's signed physician's orders, dated September 5, 2018, revealed the following: nectar thick liquids; monitor coughing at meals; aspiration risk.

The PD was interviewed on January 8, 2019, at 9:40 AM. The PD acknowledged that Individual #1's prescribed diet was not followed by drinking her beverages without the benefit of thickener in them.















Plan of Correction:

460 Each client must receive a nourishing, well-balanced diet including modified and specially prescribed diets.

The QIDP Coordinator will train the QIDP and all Direct Support Professionals on the importance of ensuring each client receives a nourishing, well-balanced diet including modified and specially prescribed diets. Training will review current prescribed diets and focus on, but not be limited to the importance of complying to, and correctly documenting, prescribe fluid restrictions and modifying liquid to the correct consistency, all as per prescribed diet. This training will be complete by February 7, 2019 and signed and dated by the Program Director to ensure completion. The QIDP will ensure all staff are trained by comparing the completed training sheets to the staff schedule to ensure completion. Training records will be maintained by the Human Resources Department. To reinforce learning, the Registered Dietitian will conduct additional training during the February 21, 2019 staff meeting, which is mandatory for staff to attend. Documentation will follow the steps above.

Following each annual dietary assessment, and interim as needed, the QIDP will train the all Direct Support Professionals on each individual's diet. The QIDP will be responsible for updating the menu binder with the correct diet on an annual basis, and after interim changes.

The Interdisciplinary team will work with the Director of Nursing to modify the fluid restriction tracking procedure to specify the number of ounces of fluid to offer individual #4 throughout the day and prompt staff to document the number of additional ounces he consumes. The QIDP will train all Direct Care Staff within seven business days. Documentation will follow the steps above.

To ensure ongoing compliance, a supervisory staff will make unannounced observations of meals and medication administration times to ensure all individuals are consuming meals according to their prescribed diets, and that fluids are modified to their correct consistency at all times. This includes, but is not limited to, ensuring #4's fluid restriction is documented correctly by accounting for all beverages consumed, and individuals #1 and #5 receive liquids thickened to the proper consistency. These monitoring's will begin February 7, 2019 and all staff will be observed at least three times by March 1, 2019. Feedback will be given immediately. After each observation, all feedback will also be documented on a tracking grid developed by the Program Director which and specify whether each individual's prescribed diet is followed. The QIDP Coordinator will review, sign, and date all observation March 1, 2019 to ensure compliance. The QIDP will ensure all staff is observed by comparing completed observation forms with the staff schedule.

If there are no concerns, meaning all beverages are prepared for meal and medication administration to the correct consistency, and fluid restrictions are accurately followed, all staff will be observed two additional times in the month of March. If concerns are noted the staff members making the error will continue to be observed at least two times per week until there are three successful, consecutive, observations and the procedure described above will be followed.

Moving forward, the supervisory team will complete at least four 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 QIDP 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.