QA Investigation Results

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


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Initial Comments:

A monitoring survey was conducted on October 15, and 16, 2018, to determine compliance with the requirements of 42 CFR Part 483, Subpart I Requirements for Intermediate Care Facilities and to determine the progress made in correcting the deficiencies cited during the certification survey completed on April 9, 2018. The census during the survey was five. Three 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 documentation review and staff interview, it was determined that the facility failed to complete a physical examination quarterly for two of the three individuals in the sample (Individuals #1 and #2).

The findings included:

A. Individual #2

1. A review of the facility's plan of correction revealed that to correct the deficient practice for this individual, a nursing quarterly examination was to be completed by April 13, 2018.

2. A focused review of Individual #2's record was conducted on October 15, 2018. This review revealed no documentation of a quarterly nursing assessment since February 7, 2018.

3. The program coordinator (PC) was interviewed on October 15, 2018, at 1:05 PM. The PC confirmed that Individual #2 was not provided with quarterly nursing assessments.

B. Individual #1

1. A review of the facility's plan of correction revealed that to correct the deficient practice for this individual, a nursing quarterly examination was to be completed by April 13, 2018.

2. A focused review of Individual #1's record was conducted on October 15, 2018. This review revealed documentation of a quarterly nursing assessment was completed on May 1, 2018. Further review revealed no documentation of a quarterly nursing after this date.

C. The PC was interviewed on October 15, 2018, at 1:00 PM. The PC confirmed that Individual #1 was not provided with quarterly nursing assessments.









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 ensuring nursing services 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, the need complete an in-person assessment at least three time a year, and consult with the Primary Care Physician to complete the fourth. Training will take place by November 6, 2018 and will be documented on a training form. The Program Director will sign and date the training forms to ensure completion, and the form will be kept in the employee's Human Resources file.

The Quarterly assessment for individual #1 was completed by October 16, 2018. Individual #2 is scheduled to see the Primary Care Physician for the annual assessment and physical on October 30, 2018. The Director of Nursing will review quarterly and physical assessment to ensure completion and document her review by signing and dating the form. The form will be maintained in the individual's record.

To ensure future compliance, a tracking sheet specific to quarterly nursing assessments and annual physical exams was developed by the previous Director of Nursing. Schedules of when the quarterly nursing assessments are due are specified in the tracking sheet. The Director of Nursing will retrain the Health Services Coordinator by November 6, 2018. The Director of Nursing will add appointments to the Health Services Coordinator's Outlook calendar on days which quarterly assessments need to be completed to further ensure they are completed by their designated due date. The Health Services Coordinator will acknowledge these appointments by accepting them, and sending confirmation to the Director of Nursing. Documentation will be maintained in the Outlook calendar.

Moving forward, additional services were integrated to assist with review of the tracking sheet and timely completion of the ICF Quarterly Assessments. It is integrated into the responsibilities of the Administrative Community LPN. This position will collaborate a monthly review with the facilities Health Services Coordinator, Administrative LPN, and the Director of Nursing in person or by phone on the 2nd Thursday of each month. There will be a review the tracking sheet for the current month and compare it to the electronic health record to ensure that Nursing Assessments are completed. Any outstanding assessments will be completed within 24 hours by the Health Services Coordinator, or credentialed designee.

The Director of Nursing will email the ICF team each month after the review of the tracking sheet is completed. A status update will be provided. A copy of the email will be printed off by the QIDP to be maintained in the Plan of Correction binder for up to a year and confirmed as resolved by the ICF Director and the Director of Nursing.

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)(2) STANDARD
DRUG ADMINISTRATION

Name - Component - 00
The system for drug administration must assure that all drugs, including those that are self-administered, are administered without error.



Observations:

Based on observation, record review and staff interview, it was determined that the facility failed to administer medications without error. This was noted for one of the three individuals in the sample (Individual #2).

The findings included:

Observation of the morning medication administration was conducted on October 16, 2018, between 7:35 AM and 8:51 AM. Physician orders were reviewed immediately after the completion of administration.

A. Observations revealed that Individual #2 was administered morning medications at 8:00 AM. These medications included Align, Potassium Chloride, Flomax, and vitamin B12.

B. Review of Individual #2's physician's orders dated October 15, 2018, revealed that this individual was also prescribed the medication Citrucel, one tablespoon, in eight ounces of water at 8:00 AM. This medication was not administered to this individual.

C. Review of the medication administration record (MAR) for Individual #2 revealed that the staff administering medications did not initial the document for administration of the Citrucel.

D. The program coordinator (PC) was interviewed on October 16, 2018, at 9:52 AM. The PC confirmed that Individual #2's MAR did not document that this individual received the medication Citrucel on October 16, 2018, at 8:00 AM, as prescribed by the physician.













Plan of Correction:

369 The system for drug administration must assure that all drugs, including those that are self-administered, are administered without error.

The Administrative Coordinator will train the Administrative Supervisor and all Direct Support Professional (DSP) staff on the importance of ensuring that that all drugs are administered without error. The training will include, but not be limited to, comparing all medication to the kardex to ensure all prescribed medication at a given time are administered. This training will be complete by November 11, 2018 and signed and dated by the Program Director to ensure completion. The Administrative Supervisor will ensure all staff are trained by comparing the completed training sheets to the staff schedule to ensure completion.

Following the medication error, the nurse was consulted, who consulted the Primary Care Physician for a verbal order as to how to proceed. This was done October 16, 2018. The staff member responsible for the medication error will be retrained and receive disciplinary action according to agency policy.

A supervisor will conduct unannounced observations, at varied medication administration times, to ensure that all medication is administered without error which includes ensuring that all medication s prescribed at a given time are administered. Observations will be recorded on tracking grid developed by the Program Director and will specify whether the medication is administered without error. These observations will begin November 11, 2018 and all DSP staff who work in the home will be observed at least three times by December 15, 2018. If staff does not ensure medication is administered without error, 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 administering all medication without error.

After two successful observations the monitoring will be faded to two additional times by January 15, 2019, then two times per year and conducted during the time of each staff member's semi-annual medication administration training. Observations November to January 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 without error. 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, and there is an error in administration, 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.



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 observations, record review and staff interview, it was determined that the facility failed to ensure individuals were provided with specially prescribed diets for two of the three individuals in the sample (Individuals #1 and #3).

The findings included:

A. The evening meal was observed on October 15, 2018, between 5:10 PM and 5:50 PM. In addition, observation of the morning meal was conducted on October 16, 2018, between 7:00 AM and 7:25 AM.

B. Individual #3

1. During the evening meal, staff poured approximately eight ounces of milk into Individual #3's glass. Individual #1 poured approximately eight ounces of water and eight ounces of red drink into Individual #3's glasses. The evening meal consisted of approximately four ounces of fish (chopped into rice sized pieces); one cup of mashed potatoes; and approximately one-half cup of peas (chopped into rice sized pieces). Individual #3 ate this meal and drank the beverages from the glasses provided. This individual was encouraged to also drink an eight ounce Ensure Enlive. Individual #3 drank the Ensure from the bottle while watching television after dinner.

2. During the morning meal, staff poured approximately eight ounces of orange juice into a glass and approximately eight ounces of water into another glass. Individual #3 drank the beverages from the glasses that were provided.

3. Physician orders dated October 15, 2018, were reviewed. These orders included, but not limited to: two servings of yogurt at dinner daily; and give beverages four ounces at a time.

4. The program coordinator (PC) was interviewed on October 16, 2018, at 9:30 AM. The PC acknowledged that Individual #3 did not receive the specially prescribed diet in accordance with the above-mentioned physician's orders.

C. Individual #1

1. During the evening meal, staff served this individual a whole piece of fish (approximately four inches in length and three inches wide). Individual #1 used his spoon to break apart the fish into approximately one inch by one-inch pieces and ate them.

2. Physician orders dated October 15, 2018, were reviewed. These orders included, but not limited to: diet chopped pea sized consistency.

3. The PC was interviewed on October 16, 2018, at 9:30 AM. The PC acknowledged that Individual #1 did not receive the specially prescribed diet in accordance with the above-mentioned physician's orders.







Plan of Correction:

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

The Director or Nursing will train the Health Services Coordinator on the importance of each client receiving a nourishing, well-balanced diet including modified and specially-prescribed diets. This includes, but is not limited to, comparing dietary recommendations to physician's orders each month to ensure they match, and if not, obtain a clarifying order from the Primary Care Physician. Training will take place by November 6, 2018 and will be documented on a training form. The Program Director will sign and date the training forms to ensure completion and the form will be kept in the employee's Human Resources file.

The Health Services Coordinator (HSC) will review recommendations from the Registered Dietitian and compare them to the physician orders for individual #3 and all individuals to identify discrepancies. The HSC will communicate discrepancies to the Interdisciplinary Team, including the Registered Dietitian and Primary Care Physician to obtain clarification. A verbal order will be obtained correcting the discrepancy. This will be completed by November 13, 2018. The Director of Nursing will ensure completion by signing and dating the clarifying verbal order. The VO will be maintained in the individual's record.

This will be completed by the Health Services Coordinator each month for the next six months, prior to the start of each month. The Health Services Coordinator will document his review by signing and dating the physician's orders. The Health Services Coordinator will also document the results of his review, and any corrective measures taken in an e-mail to the Director of Nursing, prior to the start of each month. The Director of Nursing will print and sign the e-mail documenting her review. The e-mail will be maintained in the Plan of Correction binder.

Moving forward, within 24 hours of all dietary recommendations, the Health Services Coordinator will consult the Interdisciplinary Team, including the Primary Care Physician, and obtain a verbal order. Prior to the next month, the Health Services Coordinator will review the Physician's Orders to ensure they accurately reflect the prescribed diet. For the next two months, the review will continue as stated above. If no errors are found, and the physician's orders match the recommendations of the Registered Dietitian, the process will fade to annually, or interim if applicable, following all changes in dietary recommendations. If errors are found, the process will continue for the remainder of the calendar year.

The Director of Food Services will train the Program Coordinator and incoming QIDP on the importance of each client receiving a nourishing, well-balanced diet including modified and specially-prescribed diets. This includes, but is not limited to, an in-person, hands on, demonstration of how to properly prepare all foods, including fish, using a food processor to ensure it is prepared as per their prescribed diet. Following this training, the Coordinator will complete live demonstration training for all Direct Support Professional (DSP) staff focusing on, but not limited to the importance of cutting food to the correct size, modifying food to the correct consistency, adding moisture appropriately, and providing meal supplements, all as per their prescribed diet. Training will take place for the Coordinator and QIDP by November 6, and for DSP staff by November 15, 2018 and will be documented on a training form. The Program Director will sign and date the training forms to ensure completion and the form will be kept in the employee's Human Resources file.

Following each quarterly 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 a quarterly basis, and after interim changes.

To ensure ongoing compliance, a supervisory staff will make unannounced observations of breakfast, packed lunches, and dinner to ensure all individuals are consuming meals according to their prescribed diets. This includes, but is not limited to, ensuring individual #3 receives the correct number of yogurts with his meal, and individual #1 and all individuals receive their food chopped, with moisture added, as prescribed. These monitoring's will begin November 15, 2018 and all staff will be observed at least three times by December 15, 2018. Feedback will be given immediately. After each observation, all feedback will also be documented on the appropriate agency form used to ensure each individual's prescribed diet is followed. The QIDP Coordinator will review, sign, and date all observation forms to ensure compliance. Forms will be maintained in the plan of corrections binder. The QIDP will ensure all staff is observed by comparing completed observation forms with the staff schedule.

If there are no concerns, meaning all individuals consumed meals according to their prescribed diet, all staff will be observed one additional time, and each individual' food for all three meals will be observed two additional times by January 15, 2019. 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 be take effect.