QA Investigation Results

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


There are  21 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 survey was conducted January 16-18, 2019, to determine compliance with the requirements of the 42 CFR Part 483, Subpart I Requirements for Intermediate Care Facilities. The census during the survey was six and the original sample consisted of three individuals. Five deficiencies were cited.




Plan of Correction:




483.440(d)(1) STANDARD
PROGRAM IMPLEMENTATION

Name - Component - 00
As soon as the interdisciplinary team has formulated a client's individual program plan, each client must receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan.




Observations:

Based on record review and staff interview, it was determined that the facility failed to ensure continuous active treatment was implemented. This was noted for all six individuals in the home (Individuals #1, #2, #3, #4, #5, and #6). The findings included:

A) A physical plant inspection was conducted on January 17, 2019, between 1:45 PM and 2:15 PM. The program director (PD) accompanied the surveyors during this inspection. These observations revealed liquid laundry detergent and liquid fabric softener containers sitting on top of the dryer in an unlocked laundry room.

The PD was interviewed at that time. The PD acknowledged that cleaning supplies are to be kept locked, as indicated in all six individuals' comprehensive assessments and consents.

B) Individuals #1, #2, and #3's records were reviewed on January 18, 2019. This review revealed the following:

Individual #1

- A financial goal was discontinued on July 26, 2018. There was no documentation that Individual #1 had another financial goal to date.

- A self medication administration goal was achieved on November 16, 2018. There was no documentation that Individual #1 had another goal to date.

The program coordinator (PC) was interviewed on January 18, 2019, at 10:35 AM. The PC confirmed that Individual #1 did not have continuous active treatment in the areas of financial and medication administration.

Individual #3

- A communication goal was achieved on September 17, 2018. A new communication goal was not implemented until December 19, 2018.

- A personal care goal was discontinued on October 8, 2018. A new personal care goal was not implemented until December 17, 2018.

The PC was interviewed on January 18, 2019, at 10:34 AM. The PC confirmed that Individual #3 did not have continuous active treatment in the areas of communication and personal care.

Individual #2

- A personal care goal was achieved on September 12, 2018. The new goal, which was a continuation of steps from the previous goal, was not implemented until December 26, 2018.

The PC was interviewed on January 18, 2019, at 10:36 AM. The PC confirmed that Individual #2 did not have continuous active treatment in the area of personal care.









Plan of Correction:

249 As soon as the interdisciplinary team has formulated a client's individual program plan, each client must receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan.

The liquid laundry detergent and liquid fabric softener was immediately removed from the laundry room and locked, as per the individual's program plan.

The Program Supervisor will train all Direct Support Professional staff on the importance of providing a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan. This will include, but not be limited to, the importance of ensuring household cleaning supplies and poison are locked, consistent with each individual's current program plan. The training will take place by February 15, 2019 and the Program Coordinator will sign and date the training to ensure completion. The Program Supervisor will ensure all DSP staff is trained by comparing completed training records with the staff schedule. Training records will be maintained in the personnel files.

Beginning February 15, 2019, to ensure compliance, the Program Supervisor will conduct random checks of the entire home to ensure all household cleaning supplies and poison are locked three times a week for two weeks. If no problems are found, the monitoring will be reduced to two times a week for two weeks and then one time a week for two weeks. If household cleaning supplies or poison is found in an unlocked area, the staff involved will receive corrective action as per agency policy and the monitoring will continue from the beginning. The Program Supervisor, or designee, will document the date and time the check was complete and whether or not the cleaning supplies were found in an unlocked area on a tracking grid developed by the Program Director. The Program Coordinator will review, sign and date the calendar weekly for two months then at the end of the tracking period to ensure completion and address all concerns immediately with the Program Supervisor.

Moving forward, supervisory personnel will check the home when visiting to ensure all household cleaning supplies and poison are locked.

The QIDP Coordinator will train the QIDP on the importance of providing a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan. This will include, but not be limited to, the importance of ensuring each individual has basic goal, demonstrating continuous active treatment, in the areas of financial management, communication, self-medication management, and personal care, and the importance of implementing a new goal immediately upon achieving/discontinuing the previous goal. The training will take place by February 15, 2019 and the Program Director will sign and date the training to ensure completion. Training records will be maintained in the personnel files.

The QIDP will develop a baseline evaluation for Individual #1's financial goal and self-medication administration goal and individual #3's communication goal. All other goals for individuals #1, #2, and #3 were reviewed at the time of the survey and deemed appropriate. Baseline data will be collected by Direct Support Professional staff on at least five occasions prior to March 1, 2019. The QIDP Coordinator will review the baseline evaluation and document her review by signing and dating the training plans, and initialing and dating the Plan of Correction tracking grid by March 1, 2019.

Pending the results of the baseline data, training plans will be developed by the QIDP for individual #1 and #3 to improve their skills from their current functioning level by reducing the intensity or number of prompts necessary for task completion. This will be in place by March 15, 2019. The QIDP Coordinator will review the training plans and document her review by signing and dating the training plans, and initialing and dating the Plan of Correction tracking grid by March 22, 2019.

The QIDP and QIDP Coordinator will work together to review all training plans for Individuals #4, #5, and #6 and revise them as necessary, including, but not limited to situations in which the client is failing to progress toward identified objectives after reasonable efforts have been made. Revisions will include re-baselining any goal that has been in place for more than one year, and re-writing the training plan to improve skills from each Individual's current functioning level by reducing the intensity or number of prompts necessary for task completion. This review will be completed by March 31, 2019. The QIDP Coordinator will document her review, and findings by summarizing them in an e-mail to the QIDP and Program Director, as well as initialing and dating the Plan of Correction tracking grid. The QIDP Coordinator will print, sign, and date e-mail which will be maintained in the POC binder.

For the next two months, all training plans in the home will be reviewed by the QIDP at least one time every two weeks and revised as necessary. The QIDP will document her review by signing and dating the program plan comment sheet, even if no revisions have been made.

To ensure compliance, all training plans in the home will be reviewed by the QIDP Coordinator one time per month and revised as necessary, to ensure progress toward identified objectives have been made. Feedback will be given to the QIDP and Program Director via e-mail. The review will be documented by signing and dating the Plan of Correction tracking grid. Within one week, the QIDP Coordinator will meet with the QIDP to review all program plans and ensure all feedback is implemented. The QIDP Coordinator will document her review by signing and dating the program plan.

Moving forward, the QIDP Coordinator and the Interdisciplinary Team will be updated on each Individual's program plan during their monthly meeting by the QIDP. Minutes will be documented in the Individual's electronic health record.

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



483.460(a)(3) STANDARD
PHYSICIAN SERVICES

Name - Component - 00
The facility must provide or obtain preventive and general medical care.




Observations:

Based on record review and staff interview, it was determined that the facility failed to provide general and preventative healthcare. This was noted for the only individual in the sample who was not provided an annual physical examination by a physician (Individual #1). The findings included:

A) Individual #1's record was reviewed on January 17-18, 2019. This review revealed a report of a physical examination conducted on August 23, 2017. There was no documentation in this individual's record to indicate that a physical examination was conducted to date.

B) The nurse was interviewed on January 17, 2019, at 10:35 AM. The nurse confirmed that Individual #1 did not have an annual physical examination performed by a physician, since August 23, 2017.








Plan of Correction:

322 The facility must provide or obtain preventive and general medical care.

The Director of Nursing will train the Health Services Coordinator and the Administrative Assistant on the importance of ensuring the facility provides or obtains preventative and general medical care, which includes ensuring all individuals have a physical examination preformed annually. Training will be complete by February 15, 2019 and signed by the Program Director to ensure compliance. Training records will be maintained in the personnel files.

Individual #1's annual physical was completed on January 30, 2019. The record for Individuals #2 and #3 was reviewed at the time of the survey and it was noted they had a physical examination preformed annually. The Health Services Coordinator will check the record of the remaining individuals in the facility to ensure they had an annual physical and document their results in an e-mail to the Director of Nursing and Program Director. If individuals did not have a physical examination the Administrative Assistant will be copied, and the Administrative Assistant will schedule the physical examination within 24 hours. The Director of Nursing will respond to the e-mail(s) documenting receipt. The Program Director will add the e-mail to the Plan of Correction binder. If an individual needs a physical examination, the form will be placed in the individual's record following their appointment.

Moving forward, the Health Services Coordinator will ensure that the facility provides or obtains preventive and general medical care which includes ensuring each individual has a annual physical evaluation. The Health Services Coordinator will monitor compliance with an ongoing tracking tool created by the Director of Nursing. The tracking tool will be specific to ensuring annual health care requirements, including the annual physical, are current and available in the program. The status of any pending nursing services or medical services will also be noted on this form.

To assure compliance, for the next two months the Director of Nursing and Health Services Coordinator will review the tracking tool monthly during their supervision meetings. The Director of Nursing will sign and date the tool documenting her review. Pending noted compliance, defined as all annual health care requirements, including the annual physical, are current, the formal review process will continue for two months, then the Health Service Coordinator will be responsible for monitoring compliance on an on-going basis, seeking interim assistance from the Director of Nursing during their monthly meetings.

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.





483.460(g)(2) STANDARD
COMPREHENSIVE DENTAL TREATMENT

Name - Component - 00
The facility must ensure comprehensive dental treatment services that include dental care needed for relief of pain and infections, restoration of teeth, and maintenance of dental health.



Observations:

Based on record review and staff interview, it was determined that the facility failed to ensure dental treatment was provided for the individuals' teeth restoration. This was noted for two of the three individuals in the sample (Individuals #1 and #2). The findings included:

Individual #1

A) Individual #1's record was reviewed on January 17, 2019. The review revealed that this individual had a dental examination on March 13, 2018, for periodontal maintenance. The report from this appointment indicated that tooth #28 was fractured with pulpal exposure and recommended a root canal with post and crown be performed.

Follow up appointments were performed for the periodontal maintenance on April 4, 2018, and June 18, 2018. There was no documentation in Individual #1's record to indicate that a root canal and crown were performed.

B) The nurse was interviewed on January 17, 2019, at 11:45 AM. The nurse confirmed that Individual #1 did not have the recommended dental work performed to tooth #28 to date.

Individual #2

A) Individual #2's record was reviewed on January 17, 2019. The review revealed this individual had a dental appointment on July 16, 2018, for periodontal maintenance. The report from this appointment indicated recommendations, which included the need for "full mouth x-rays, root planning and scaling, extraction #23, smooth #28 and restore caries #14".

Individual #2 had another dental examination on October 22, 2018. The report from this appointment indicated that tooth #23 was extracted; however, this individual had not yet had the other recommended dental procedures completed.

B) The nurse was interviewed on January 17, 2019, at 2:30 PM. The nurse confirmed that Individual #2 did not have the recommended dental procedures for the restoration and maintenance of dental health to date.








Plan of Correction:

356 The facility must ensure comprehensive dental treatment services that include dental care needed for relief of pain and infections, restoration of teeth, and maintenance of dental health.

The Director of Nursing will train the Health Services Coordinator and the Administrative Assistant on the importance of ensuring the facility provides or obtains ensure comprehensive dental treatment services that include dental care needed for relief of pain and infections, restoration of teeth, and maintenance of dental health. This includes, but is not limited to, ensuring recommended dental procedures for the restoration and maintenance of dental health is preformed. Training will be complete by February 15, 2019 and signed by the Program Director to ensure compliance. Training records will be maintained in the personnel files.

Both individual #1 and individual #2 immediately had the recommended dental appointments scheduled. Individual #1 is scheduled for 01/24/19. Individual #2 is scheduled for 04/05/2019. Individual #3's record was reviewed at the time of the survey and it was determined that all recommended dental procedures for the restoration and maintenance of dental health was preformed. The Health Services Coordinator will check the record of the remaining individuals in the facility to ensure they all recommended dental procedures for the restoration and maintenance of dental health was preformed and document their results in an e-mail to the Director of Nursing and Program Director. If individuals did not have recommended dental procedures for the restoration and maintenance of dental health was preformed the Administrative Assistant will be copied, and the Administrative Assistant will schedule the dental appointment within 24 hours. The Director of Nursing will respond to the e-mail(s) documenting receipt. The Program Director will add the e-mail to the Plan of Correction binder. If an individual needs a physical examination, the form will be placed in the individual's record following their appointment.

Moving forward, the Health Services Coordinator will ensure that the facility provides or obtains comprehensive dental services which includes, but is not limited to, recommended dental procedures for the restoration and maintenance of dental health. The Health Services Coordinator will monitor compliance with an ongoing tracking tool created by the Director of Nursing. The tracking tool will be specific to ensuring annual health care requirements, including the annual physical, are current and available in the program. The status of any pending nursing services or medical services will also be noted on this form.

To assure compliance, for the next two months the Director of Nursing and Health Services Coordinator will review the tracking tool monthly during their supervision meetings. The Director of Nursing will sign and date the tool documenting her review. Pending noted compliance, defined as all the facility following all recommended dental procedures for the restoration and maintenance of dental health, the formal review process will continue for two months, then the Health Service Coordinator will be responsible for monitoring compliance on an on-going basis, seeking interim assistance from the Director of Nursing during their monthly meetings.

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.


483.460(k)(3) STANDARD
DRUG ADMINISTRATION

Name - Component - 00
The system for drug administration must assure that unlicensed personnel are allowed to administer drugs only if State law permits.



Observations:

Based on record review and staff interview, it was determined that the facility failed to ensure unlicensed personnel had current training in the state required medication administration procedures. This applied to all six individuals in the home (Individuals #1, #2, #3, #4, #5, and #6). The findings included:

A) A facility investigation was reviewed on January 16, 2019. The review revealed Individual #6 did not receive a prescribed seizure medication from December 10, 2018, to December 18, 2018. This individual had a seizure on December 18, 2018, which resulted in a fall and subsequent emergency room visit.

Further review of the investigation packet revealed several staff members were identified as being out of compliance with medication administration training. The surveyor inquired about the status of these staff members' training. It was determined that one staff was not in compliance with the state's medication administration training since March 1, 2017.

B) Medication administration records from October, 2018, through December, 2018, and staff assignment sheets for the same time period, were reviewed. This review revealed the previously identified staff administered medications during this timeframe.

C) The program director (PD) was interviewed on January 17, 2019, at 3:25 PM. The PD confirmed that the identified staff continued to administer medications from March 2017, through present, to the individuals in the home. Additionally, the PD confirmed that the staff has not received medication administration training to date.






Plan of Correction:

370 The system for drug administration must assure that unlicensed personnel are allowed to administer drugs only if State law permits.

The Staff member referenced was immediately told they were out of compliance with their medication administration training and scheduled for the next class, on February 7, 2019. The referenced staff, and any staff who are out of compliance with their training, are not permitted to administer medications until testing and practicum have been completed.

The Program Director will audit the medication administration training status of the QIDP, Administrative Supervisor, and all DSP staff members to determine whether or not they are in compliance. Documentation of their status, and the measures taken to ensure they are in compliance will be documented on a tracking grid developed by the Program Director and e-mailed to the Program Coordinator, Supervisor, and that staff member. The tracking grid will be maintained in the Plan of Correction binder.

The Program Coordinator, or designee, will arrange for a Certified Medication Administration Instructor to train the all facility staff members who are out of compliance on the importance of the system for drug administration assuring that unlicensed personnel are allowed to administer drugs only if State law permits. The training will include but not be limited to the importance of all staff completing the course established by the state to administer medications prior to administering medications, and annual training requirements thereafter. The training will take place by March 1, 2019 and the Certified Medication Administration Instructor will sign and date the training to ensure completion. Training records will be maintained by the Human Resources Department. The Learning Program Assistant will send an e-mail to the Program Coordinator, Program Supervisor, and Direct Support Professional confirming they are certified. This e-mail will be printed by the Program Supervisor and placed on the plan of correction binder.

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.






483.460(l)(3) STANDARD
DRUG STORAGE AND RECORDKEEPING

Name - Component - 00
The facility must maintain records of the receipt and disposition of all controlled drugs.



Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain records of receipt and disposition of all controlled medications. This was noted for the only individual who received a controlled medication (Individual #2). The findings included:

A) A physical plant inspection was conducted on January 17, 2019, between 1:45 PM and 2:15 PM. The program director (PD) accompanied the surveyors during this inspection. During this inspection, staff explained that one of the locked kitchen cabinets contained extra medications. Upon review of the medications in the cabinet, it was noted that Individual #2's Klonopin was among these medications. (Klonopin is a controlled medication.)

B) The PD was interviewed at the time of this discovery. The surveyor inquired about the records of receipt and disposition for this controlled medication. The PD confirmed that the facility did not maintain any records for the extra doses of Individual #2's controlled medication.






Plan of Correction:

385 The facility must maintain records of the receipt and disposition of all controlled drugs.

The Program Coordinator will train the Administrative Supervisor, and in turn, the Administrative Supervisor will train all Direct Support Professional staff on the importance of maintaining records of the receipt and disposition of all controlled drugs. The training will include, but not be limited to, ensuring controlled medication is maintained double locked and a count sheet is in place from the time a controlled substance arrives on site, until it is no longer on site either because it was consumed or disposed. The training will take place by February 15, 2019 and the Program Coordinator will sign and date the training to ensure completion. The Program Supervisor will ensure all DSP staff is trained by comparing completed training records with the staff schedule. Training records will be maintained in the personnel files.

The Health Services Coordinator and the Director of Nursing properly disposed of the Klonopin based as per agency policy on January 18, 2019.

A supervisory staff member will conduct unannounced observations, at varied medication administration times, to ensure that all controlled drugs are double locked and records of the receipt and disposition of all controlled drugs are in place and accurate. Observations will be recorded on tracking grid developed by the Program Director and will specify whether the medication is double locked, and whether the count is current and accurate. These observations will begin February 15, 2019 and all DSP staff who work in the home will be observed at least two times by March 1, 2019. If staff does not ensure the medication is double locked, and records of the receipt and disposition of all controlled drugs are accurate and current, 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 records of the receipt and disposition of all controlled drugs are current and accurate.

After two successful observations the monitoring will be faded to one additional time 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. 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 ensuring there are records of the receipt and disposition of all controlled drugs which are accurate and current. The Administrative Coordinator will review to ensure compliance for the next six months, and document her review by signing and dating the tracking grid. 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, defined by administering medications without error.

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.