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:


There are  22 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 April 1-3, 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 five and the original sample consisted of three individuals. Two deficiencies were identified.





Plan of Correction:




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 accordance with physician's orders. This was noted for the only individual prescribed a medication to be taken before meals (Individual #4). The findings included:

A) The breakfast meal was observed on April 3, 2019, from 6:45AM to 7:15 AM. Medication administration was observed the same day, from 7:25 AM to 8:45 AM. Physician's orders were reviewed immediately following the medication administration.

B) Individual #4 was observed to finish his breakfast meal at 7:12 AM. This individual then received his medications at 7:43 AM. The medications included but were not limited to: Urecholine 25 milligrams (mgs), one tablet three times a day 30 minutes before breakfast, lunch, and dinner. The staff administering medications (SAM) acknowledged that this medication was prescribed 30 minutes before breakfast, and Individual #4 did not receive it at that time. The SAM informed the surveyor that the medication, Urecholine, would not be given until a verbal order was received from the doctor on how to proceed.

C) Review of signed physician's orders, dated February 1, 2019, revealed Individual #4 was prescribed Urecholine 25 mgs, "one tablet three times a day, 30 minutes before breakfast, lunch, and dinner, for urinary incontinence".

D) The nurse was interviewed on April 3, 2019, at 10:25 AM. The nurse confirmed that the medication, Urecholine 25 mgs, was not administered as ordered by the physician.







Plan of Correction:

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

The Administrative Coordinator will train the Administrative Supervisor, who will in turn train all Direct Support Professional (DSP) staff on the importance of ensuring that that all drugs are administered in compliance with the physician's orders. The training will include, but not be limited to, ensuring medications are administered as per specialized instructions, such as before meals. Training will be complete by May 10, 2019 and signed and dated by the Program Director and/or Program Administrator 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 errors, the nurse was consulted, who consulted the Primary Care Physician for a verbal order as to how to proceed. The staff members 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 in compliance with physician's orders, which includes ensuring that medications are administered as per specialized instructions, such as before meals. 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 May 10, 2019 and all DSP staff who work in the home will be observed at least two times by June 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 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 July 15, 2019, then two times per year and conducted during the time of each staff member's semi-annual medication administration training. Observations through July 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 observation, record review, and staff interview, it was determined that the facility failed to ensure specially prescribed diets were provided. This was noted for one individual in the sample (Individual #3). The findings included:

A) Observation of leisure activities in the home was conducted on April 1, 2019, from 3:30 PM to 5:30 PM. Individual #3 was observed helping staff to prepare the dinner meal in the kitchen. At 4:20 PM, this individual walked out of the kitchen to his bedroom, while eating a ham and cheese sandwich. This sandwich was not modified in consistency.

B) Individual #3's record was reviewed on April 3, 2019. The review revealed that this individual was edentulous. In addition, physician ' s orders, dated March 27, 2019, which included but not limited to, a "chopped pea sized diet, encourage low calorie snacks".

C) The program coordinator (PC) was interviewed on April 3, 2019, at 10:00 AM. The PC confirmed that Individual #3 was prescribed a chopped pea-sized diet.






Plan of Correction:

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

The QIDP will train 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 cutting food to the prescribed size and adding the appropriate amount of moisture. This training will be complete by May 10, 2019 and signed and dated by the Program 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.

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.

To ensure ongoing compliance, a supervisory staff will make unannounced observations of meals to ensure all individuals are consuming meals according to their prescribed diets. This includes, but is not limited to, ensuring individual #3 receives food cut " x " with moisture added. These monitoring's will begin May 10, 2019 and all staff will be observed at least two times by June 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 observations by June 10, 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 meals are modified as per the individual's prescribed diet, all staff will be observed two additional times in the remainder of the month. 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.