QA Investigation Results

Pennsylvania Department of Health
COMMUNITY SERVICES - HANS HERR
Health Inspection Results
COMMUNITY SERVICES - HANS HERR
Health Inspection Results For:


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Initial Comments:

A full survey was conducted May 7-10, 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 two and the sample consisted of two individuals. Seven deficiencies were identified.





Plan of Correction:




483.410(a)(1) STANDARD
GOVERNING BODY

Name - Component - 00
The governing body must exercise general policy, budget, and operating direction over the facility.




Observations:

Based on review of the facility's policies and staff interview, it was determined that the facility failed to ensure compliance with the federal regulations. The findings included:

A) The policy for behavioral programming and restrictive procedures (policy No. C.6.e.1 - IDD, Dev. 09/16) was reviewed on May 8, 2019. This review revealed the following:
- The policy did NOT indicate the hierarchy of behavioral interventions that the facility will implement.
- Section VI, E- indicates " If restrictive procedures are developed, at least one trained staff person must be available when those procedures are used. " Further review revealed restrictive techniques include chemical restraint, mechanical restraint, physical restraint for emergency situations and manual restraints. The policy did not state that staff who utilize restraint must be trained prior to application of these restrictive procedures.
- The section entitled "Chemical Restraint" states: "Use of medication to address psychiatric symptoms through a written PRN protocol is NOT considered a chemical restraint."
- The section entitled "Planned Restraint (Manual Restraint)" indicates that restrictive procedures must be used twice in a six-month period before a restrictive plan is developed. The policy did not indicate which manual restraints are permitted by the facility.

B) The facility did not present a policy and procedure to address resident conduct to be allowed or not allowed.

C) The policy for abuse and neglect (policy No. E.8.i.-CW,HR , Rev. 06/18) was reviewed on May 8, 2019. This review revealed the following:
- There was no mention of mistreatment of individuals.
- The policy did not state that the facility prohibits abuse, neglect or mistreatment of the individuals.

D) The program director (PD) was interviewed on May 8, 2019, at 3:00 PM. The PD acknowledged that the above-mentioned policy and procedures do not meet the federal regulations.







Plan of Correction:

The facility will ensure compliance with federal regulations.

A. The policy for behavioral programming and restrictive procedures will be revised to more clearly specify the hierarchy of behavioral interventions that will be implemented, ranging from most positive or least intrusive to least positive or most intrusive. The policy will state that any staff who utilize restraint must be trained prior to the application of any restrictive procedures, including restraint. The policy also will state that at least one staff person must be available when those procedures are used at the facility. Further, the policy will identify permissible restraints and those prohibited in the facility, including a statement that medications used to manage behavior must not be ordered on a PRN basis. The policy will contain the requirement that use of a single incident of restraint in an emergency situation will require the behavior needs to be addressed in a plan that may require restrictive procedures. The Behavior Specialist and facility Director will be responsible to develop the new policy.
It is the standard of Community Services in writing policies and procedures that a section of the policy must list all related policies of the organization. As part of the process in developing the policy for behavioral programming and restrictive procedures, the Behavior Specialist and facility Director will be responsible to review other existing policies to determine if they are affected.
The Vice President of IDD Services will ensure this is completed by July 1, 2019. Facility staff will be trained in the new policy by July 31, 2019.
In the future, facility policies will be reviewed annually between January-March by the QIDP and Program Manager to ensure continued compliance with federal regulations. They will prepare a written summary of the review and submit to the facility Director who will monitor completion and oversee that necessary policy revisions are completed.

B. A policy and procedure which addresses resident conduct will be developed by the facility Director by July 1, 2019. The policy will be reviewed with current residents and any involved family members, and any new admissions in the future, and staff will be trained in the new policy by July 31, 2019. The reviews will be conducted and documented by the QIDP or Program Manager. The Vice President of IDD Services will be responsible to ensure this is completed.

C. The facility's policy on abuse and neglect will be revised by the Vice President of IDD Services to include a statement prohibiting abuse, neglect, and mistreatment by May 31, 2019. The policy is reviewed annually by all facility staff and new hires are trained in the policy during their on the job training by the QIDP or the Program Manager. The policy is signed by employees and a copy maintained in their personnel files. The facility Director will ensure that all current employees are trained in the revised policy in addition to monitoring that the training is completed annually.


483.420(a)(4) STANDARD
PROTECTION OF CLIENTS RIGHTS

Name - Component - 00
The facility must ensure the rights of all clients. Therefore, the facility must allow individual clients to manage their financial affairs and teach them to do so to the extent of their capabilities.



Observations:

Based on documentation review and staff interview, it was determined that the facility failed to allow individuals to manage their own financial affairs for both of the individuals in the facility (Individuals #1 and #2). The findings included:

The financial records for the past six months were reviewed for Individuals #1 and #2, on May 9, 2019. Review of receipts for purchases revealed the following:

A) Individual #2 purchased basic clothing which included: "men's pants, fleece jog, and two novelty fleece" on October 31, 2018, at Kmart.

The program manager/qualified intellectual disabilities professional (PM/QIDP) was interviewed on May 9, 2019, at 9:45 AM. The PM/QIDP confirmed that Individual #2 should not have used his money to pay for basic clothing items.

B) Individual #1 purchased half gallons iced tea from a local convenience store on October 9, 23, and 30, 2018. In addition, this individual purchased metallic beads from the Dollar Tree on October 28, 2018, and April 14, 2019.

The PM/QIDP was interviewed on May 9, 2019, at 9:40 AM in regard to Individual #1's above-named purchases. The PM/QIDP stated that the iced tea was for Individual #1 to consume while in the home and should be reimbursed. In addition, the PM/QIDP stated that the metallic beads were used as a sensory stimulation exercise for the in-home day program activity. The PM/QIDP confirmed that the facility should pay for these items.




Plan of Correction:

The facility will ensure the rights of all clients and will allow individual clients to manage their financial affairs.

The individuals were reimbursed on May 9, 2019 for the costs of the purchases made that should have been paid for by Community Services.

The acting QIDP/Program Manager will review the financial records for individual #3 who was not at the facility at the time of the inspection, to ensure funds have been used appropriately and are legitimate. If any inappropriate purchases have been made, the acting QIDP/Program Manager will correct the problem. The findings will be reported to the facility Director by June 30, 2019.

The acting QIDP/program manager will review the financial policies to ensure they meet the regulatory requirements, and review all CSG policies with facility staff. The facility Director will ensure these reviews occur by June 15th and will be documented.

In the future the Acting QIDP/Program Manager will be responsible to enter transactions and complete monthly cash receipts and disbursements forms and submit them to another assigned Program Manager, who will review them monthly to ensure federal regulations are followed. In the event of any discrepancies or problems with use of funds,the mistakes will be corrected or individuals will be reimbursed if necessary.

From this point forward, the acting QIDP/Program Manager will ensure there is a plan for individuals to advance toward goals of more financial independence as appropriate for each individual.


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 observation and staff interview, it was determined that the facility failed to ensure that household cleaning supplies and poisons were kept locked, consistent with each individual's program plan (IPP). This was noted for both individuals in the sample (Individuals #1 and #2). The findings included:

A) A physical plant inspection was conducted on May 7, 2019, between 3:10 PM and 3:35 PM. The program manager/qualified intellectual disabilities professional (PM/QIDP) accompanied the surveyor. During the inspection, a container of dishwashing detergent pods was observed in an unlocked cabinet underneath the kitchen sink. In addition, a bottle of liquid laundry detergent was observed on the floor of the individuals' bathroom, next to the washing machine. This bottle was unlocked and accessible to the individuals.

B) The PM/QIDP was interviewed immediately following the inspection. The PM/QIDP confirmed that all cleaning supplies and poisons must be kept locked when not in use, as indicated in Individual #1's and #2's IPP.





Plan of Correction:

The facility will ensure that household cleaning supplies and poisons are locked, to be consistent with safety skills and precautions in the IPP.

All items (liquid detergent, dishwashing pods) were locked immediately following the walkthrough of the home on May 7, 2019.

All staff will be retrained in the safety skills and precautions for each individual related to locking poisons. This training will be provided by the Acting QIDP/Program Manager and will be completed by June 15, 2019. The facility Director will confirm that training has been completed.

In order to ensure that individuals are not affected by this deficient practice again, locking poisons has been added to the Shift checklists as of May 18, 2019. In addition, unannounced monitoring observations will be done 3 times a week by the Acting QIDP/Program Manager over various shifts to ensure that poisons are locked. The QIDP/Program Manager will document dates and times on a form. The facility Director will monitor completion of the observations by reviewing the form twice a month. If any violations are found during the observations, the situation will be corrected immediately and staff will be retrained by the QIDP/Program Manager.

Observations will be faded to 2 times a week as compliance with the safety precautions is shown at 100% for a consecutive period of 3 months. After another consecutive period of 3 months at 100% compliance, the observations will be discontinued.


483.440(f)(1)(i) STANDARD
PROGRAM MONITORING & CHANGE

Name - Component - 00
The individual program plan must be reviewed at least by the qualified intellectual disability professional and revised as necessary, including, but not limited to situations in which the client has successfully completed an objective or objectives identified in the individual program plan.

Observations:

Based on record review and staff interview, it was determined that the facility failed to advance program plans when an individual successfully completed identified objectives. This was noted for both individuals in the sample (Individuals #1 and #2). The findings included:

A) The record of Individual #1 was reviewed on May 9-10, 2019. This review revealed training programs in the four basic areas. Individual #1 achieved the goal plan to use a name stamp in January 2019 but continued to work on the same step of this goal plan. Another goal plan to hold his money pouch was achieved in March 2019 but continued to work on the same step of this goal plan. Individual #1 achieved the goal plan to hold the shower wand in January 2019 but continued to work on the same step of this goal plan. The medication goal plan was achieved in January 2019 as well, but Individual #1 continued to work on the same step of this goal plan.

The program manager/qualified intellectual disabilities professional (PM/QIDP) was interviewed May 10, 2019, between 9:15 AM and 9:40 AM. The PM/QIDP confirmed that Individual #1 achieved the above-mentioned goals but was not advanced to the next step.

B) Individual #2's record was reviewed on May 9-10, 2019. The review revealed that this individual achieved his self-medication goal in January 2019 and has continued to work on this goal. A new goal in the area of self-medication was not been initiated to date.

The PM/QIDP was interviewed on May 10, 2019, at 10:50 AM. The PM/QIDP confirmed that Individual #2's program plan in the area of self-medication was not advanced when the goal was achieved.





Plan of Correction:

The facility will review and revise individual program plans and ensure they are revised as necessary based on the individual's progress in completion of goals and objectives.

A. The QIDP will be responsible to rewrite the goals for individual #1 to reflect current state of progress and clearly identify which goal step is in place for staff to follow. The QIDP will retrain all staff in the revised goals. The facility Director will monitor that the goals have been completed and that the training has been done by June 15, 2019.

B. The QIDP will be responsible to rewrite the goals for individual #2 to reflect current state of progress and clearly identify which goal step is in place for staff to follow. The QIDP will retrain all staff in the revised goals. The facility Director will monitor that the goals have been completed and that the training has been done by June 15, 2019.

The QIDP will determine how to measure the individual's progress in goal completion, using percentages, and report on progress so that staff knows when each level is achieved. The QIDP is responsible to report on goal progress monthly The facility Director will ensure that goals are rewritten and revised, with staff trained and new plans in place by June 15th.

The QIDP will be responsible to monitor goal progress and revise the plan(s) to ensure continued learning occurs once an objective is met. A Program Manager will be responsible to review documentation monthly to ensure compliance.



483.440(f)(3)(ii) STANDARD
PROGRAM MONITORING & CHANGE

Name - Component - 00
The committee should insure that these programs are conducted only with the written informed consent of the client, parents (if the client is a minor) or legal guardian.



Observations:

Based on record review and staff interview, it was determined that the facility's human rights committee (HRC) failed to ensure written informed consent prior to approval of restrictive procedures. This was noted for the only individual in the sample who was admitted within the past year (Individual #1). The findings included:

A) The record of Individual #1 was reviewed on May 9-10, 2019. This review revealed restrictive procedures which included a wheelchair seatbelt cover, and alarms on the exterior doors of the facility, as well as this individual's bedroom door. The HRC approved these restrictive procedures on October 19, 2018. The written informed consents for these restrictive procedures were not obtained until October 22, 2018.

B) The program manager/acting qualified intellectual disabilities professional (PM/QIDP) was interviewed on May 9, 2019, at 11:20 AM. The PM/QIDP confirmed that the facility's HRC approved these restrictive procedures prior to written informed consent being obtained for Individual #1.





Plan of Correction:

The Human Rights Committee should insure that programs using restrictive procedures are put in place only after informed consent is obtained.

For individual #1,in the future, written informed consent will be obtained for all restrictive procedures prior to approval from the HRC.

For all individuals, the Behavior Specialist will outline in writing the process to follow for HRC approval to include that informed consent is obtained prior to the committee review and implementation of the restrictive procedure. The process will include situations which may require verbal informed consent and verbal HRC approval to ensure safety and well being. That is, situations where restrictive procedures are needed for an emerging behavior(s), for example alarms on windows or doors for eloping; or increased psychotropic medication due to increased behaviors. The process will also include the requirement that when verbal informed consent and verbal HRC approval are obtained for these types of unforeseen situations, they will be immediately followed by written informed consent. The process will include that the HRC is responsible to ensure written informed consent is obtained prior to the committee's approval. This will be completed by July 1, 2019 and submitted to the QIDP/Program manager for review and approval. The HRC procedures will be reviewed and the committee members trained in their responsibilities by the Behavior Specialist at their next scheduled meeting on July 19, 2019. In addition the Behavior Specialist will ensure that the date of program implementation is documented on the signature form as confirmation that it occurs after consent and approval are provided.

The QIDP/program manager will confirm that written consent is included in the record for any individual with a restrictive plan, each time the HRC reviews the plans. If there is no such documentation available, the QIDP/program manager will follow up with the behavior specialist.


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 physical examination quarterly for one of the two individuals in the sample (Individuals #1). The findings included:

A) The record of Individual #1 was reviewed on May 9-10, 2019. This review revealed a nursing assessment dated September 20, 2018. The next nursing assessment was conducted on January 27, 2019, four months later.

B) The nurse was interviewed on May 9, 2019, at 3:40 PM. The nurse confirmed that the nursing assessment was not conducted on a quarterly basis.








Plan of Correction:

Quarterly nursing physical assessments will be completed for the individuals.

On May 16, 2019, the RN compiled a list of due dates for quarterly nursing assessments for all individuals and has given the list to the QIDP/program manager and the LPN. The dates also have been posted on the large hanging calendar at the home. The RN trained the LPN on May 29, 2019 in the responsibility to complete the nursing assessment according to the quarterly schedule.

The QIDP/program manager will be responsible to review the individuals' records to see that the quarterly assessments have been completed and entered. Record reviews will be completed on a monthly basis by the QIDP/Program Manager to ensure compliance with the regulation. The date of the record reviews will be noted in a log maintained by the QIDP/Program Manager.


483.460(f)(2) STANDARD
COMPREHENSIVE DENTAL DIAGNOSTIC SERVICE

Name - Component - 00
Comprehensive dental diagnostic services include periodic examination and diagnosis performed at least annually.



Observations:

Based on record review and staff interview, it was determined that the facility failed to ensure comprehensive dental services were performed at least annually. This was noted for the only new admission within the past year (Individual #1). The findings included:

A) The record of Individual #1 was reviewed on May 9-10, 2019. This review revealed that this individual had dental restoration completed on November 30, 2017. Individual #1 was admitted to this facility on September 21, 2018. There was no documentation in the record to indicate that a dental examination was performed since 2017.

B) The nurse was interviewed on May 9, 2019, at 3:25 PM. The nurse confirmed that Individual #1 did not have a dental examination at least annually.













Plan of Correction:

The facility will ensure that comprehensive dental exams are performed at least annually for each individual.

For individual #1, a dental appointment was completed for May 29, 2019, for an initial consultation and evaluation. The practice will schedule the next appointment upon receipt of history and insurance forms, which will be done by the nurse by June 7, 2019.
The nurse also will review the records of all individuals to make sure that all necessary appointments have been scheduled. This review will occur by June 7, 2019 and the results of the review will be communicated to the QIDP/Program Manager.

To prevent missing future annual dental exams for all individuals, the LPN will review the appointment schedule at the beginning of every month and confirm the schedule with the QIDP/Program Manager. The nurse also will review all documentation after each appointment so that follow through will happen for recommendations and future appointments. The nurse's review will be noted in the medical appointment section of the individuals' record. The QIDP/Program Manager will be responsible to review the nurse's documentation in the records on a monthly basis to ensure it is complete, if there have been appointments.