QA Investigation Results

Pennsylvania Department of Health
DEVEREUX PA ADULT SERVICES - YEARSLEY
Health Inspection Results
DEVEREUX PA ADULT SERVICES - YEARSLEY
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 December 6-7, 2018, to determine compliance with the requirements of 42 CFR Part 483, Subpart I Requirements for Intermediate Care Facilities. The census during the survey was five individuals. Two deficiencies were identified.





Plan of Correction:




483.460(c)(3)(iii) STANDARD
NURSING SERVICES

Name - Component - 00
Nursing services must include, for those clients certified as not needing a medical care plan, a review of their health status which must be on a quarterly or more frequent basis depending on client need.



Observations:

Based on record review and staff interview, it was determined that the facility failed to complete a nursing physical examination on a quarterly basis for two of the three individuals in the sample (Individuals #2 and #3). The findings included:

A) A focused review of Individual #2's record was conducted on December 6, 2018. The review revealed that there was no nursing physical examination conducted during October 2018. The last physical examination by a medical professional for Individual #2 was conducted in July 2018.

B) A focused review of Individual #3's record was conducted on December 6, 2018. The review revealed that there was no nursing physical examination conducted during October 2018. The last physical examination by a medical professional for Individual #3 was conducted in July 2018.

C) The program director (PD) was interviewed on December 6, 2018, at 3:05 PM. The PD confirmed that Individuals #2 and #3 did not have the benefit of a physical examination by a medical professional performed on a quarterly basis.






Plan of Correction:

336 Nursing services must include, for those clients certified as not needing a medical care plan, a review of their health status which must be on a quarterly or more frequent basis depending on client need.
The Director of Nursing will train the Health Services Coordinator on the importance of providing nursing services that include, for those clients certified as not needing a medical care plan, a review of their health status which must be on a quarterly or more frequent basis depending on client need. Training will include, but not be limited to, ensuring a quarterly nursing physical examination is completed every 90 days for each individual, noting that the annual physical assessment by the Primary Care Physician takes place of one nursing physical examination. Training will be complete by December 17, 2018 and signed and dated by the Program Director to ensure completion. The training record will be maintained in the personnel file.
The Director of Nursing will create a quarterly nursing physical examination and annual physical tracker. For the first month of this plan beginning December 3, 2018, the Director of Nursing or an assigned designee will send outlook calendar reminders to the RN for acceptance and recognition of the quarterly nursing physical examination and annual physical. A copy of the quarterly nursing physical examination and annual physical will be sent to the Director of Nursing. Afterwards as an ongoing change of practice, monthly email reminders will be sent by the Director of Nursing or the assigned designee to each nurse to remind them of the quarterly nursing physical examination and the annual physical.
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(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 record review and staff interview, it was determined that the facility failed to ensure medications were administered in accordance with physician's orders. This was noted for four of the five individuals in the home (Individuals #1, #2, #3 and #4). The findings included:

Physician's orders and medication administration records (MAR) for Individuals #1, #2, #3 and #4 were reviewed on December 6, 2018. The reviews revealed the following:

A) Individual #1 had signed physician's orders that were dated July 17, 2018. The Plan of Care section stated that they were "90-day orders". There were no physician's orders signed after July 2018 in Individual #1's record. In addition, the MARs for August, September and October 2018, revealed that Individual #1 continued to receive all medications during that time.

B) Individual #2 had signed physician's orders that were dated July 18, 2018. The Plan of Care section stated that they were "90-day orders". There were no physician's orders signed after July 2018 in Individual #2's record. In addition, the MARs for August, September and October 2018, revealed that Individual #2 continued to receive all medications during that time.

C) Individual #3 had signed physician's orders that were dated July 18, 2018. The Plan of Care section stated that they were "90-day orders". There were no physician's orders signed after July 2018 in Individual #3's record. In addition, the MARs for August, September and October 2018, revealed that Individual #3 continued to receive all medications during that time.

D) Individual #4 had signed physician's orders that were dated July 15, 2018. The Plan of Care section stated that they were "90-day orders". There were no physician's orders signed after July 2018 in Individual #4's record. In addition, the MARs for August, September and October 2018, revealed that Individual #4 continued to receive all medications during that time.

E) The program director (PD) was interviewed on December 6, 2018, at 3:25 PM. The PD confirmed that physician's orders for Individuals #1, #2, #3 and #4 were not signed every 90 days. Additionally, the PD acknowledged that Individuals #1, #2, #3 and #4 continued to receive medication from October 2018 to present without signed physician orders.









Plan of Correction:

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

The Director of Nursing will train the Health Services Coordinator on how to audit the physician orders for the ICF homes. Training will be completed by December 31, 2018. Orders identified with a 90 day order under Plan of Care will be filed on the G drive- nurses folder- ICF Homes folder. These orders will be discussed with the PCP to determine medical necessity. If not medically necessary the Health Services Coordinator will request a discontinue order. If medically necessary the Health Services Coordinator will scan those signed orders every 90 days to the Director of Nursing who will place them into the folder noted above for auditing by the Director of Nursing. This will occur each month for the first 90 days beginning January, 2019 . Ongoing there will be an audit of signed orders every 90 days by the Health Services Coordinator as follows for April, 2019, and July, 2019, and October, 2019.

The Director of Nursing will send an email to the Program Director every 90 days January 1, 2019, April 1, 2019, July 1, 2019, and October 1, 2019 to confirm signature of physician orders. This email can be maintained in the plan of correction binder in the home.

Failure to comply with physician order signatures and ongoing audits will result in disciplinary actions as per the organizations policies.