QA Investigation Results

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


There are  17 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 November 7-9, 2018, 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 four and the original sample consisted of two individuals. Four 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 observation and staff interview, it was determined that the facility failed to ensure that household cleaning supplies were locked, consistent with each individual's program plan, for all the individuals in the home (Individuals #1, #2, #3, and #4). The findings included:

A) A physical plant inspection was conducted on November 7, 2018, between 1:00 PM and 1:30 PM. The program director (PD) was present during this inspection. The main bathroom contained a cabinet under the sink. When the surveyor opened the cabinet, a bottle of cleaning solution was found. The PD removed the bottle and acknowledged that the household cleaning supply should not be located there.

B) Interview with the clinician on November 9, 2018, at 10:10 AM confirmed that all four individuals (Individuals #1, #2, #3, and #4) were assessed and household cleaning supplies must be locked for their safety.








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 bottle of cleaning solution was immediately removed from the main bathroom cabinet and locked, as per the individual's program plan.

The Program Coordinator will train the Program Supervisor and 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 December 10, 2018 and the Program Director will sign and date the training to ensure completion. The Program Coordinator 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.

To ensure compliance, the Program Supervisor, or designee, 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; 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 Director.

Moving forward, supervisory personnel will check the home when visiting to ensure all household cleaning supplies and poison are locked. Failure to do so will lead to retraining and the policy for progressive discipline will take effect.

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.



483.440(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 was obtained on an annual basis. This was noted for the two individuals in the original sample (Individuals #1 and #2). The findings included:

A) The record of Individual #1 was reviewed on November 9, 2018. The review revealed forms for restrictive procedures to be implemented for this individual. On September 11, 2017, written informed consent was provided by the director. The next written informed consent for Individual #1 was obtained on October 8, 2018; a gap of almost one month.

B) The record of Individual #2 was reviewed on November 8-9, 2018. The review revealed forms for restrictive procedures to be implemented for this individual. On August 18, 2017, written informed consent was obtained. The next written informed consent for Individual #2 was obtained on September 10, 2018; a gap of almost one month.

C) The program director (PD) was interviewed on November 9, 2018, at 10:10 AM. The PD confirmed that Individuals #1 and #2 did not have written informed consent for restrictive procedures and that these procedures were implemented during the gap of time.









Plan of Correction:

263 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.

All individuals have current and correct consent and Human Rights Committee approval for all restrictive measures.

The Program Director will train the incoming Social Services Coordinator on the importance of providing information so that the Human Rights Committee can ensure that these programs are conducted only with the written informed consent of the client, parents, or legal guardian. This training will include, but not be limited to the importance of ensuring written informed consent is obtained prior to the HRC approval, and communicated to the HRC member via documentation on the written form. This training will be complete within 30 days of the date the Social Services Coordinator is hired and signed and dated by the Quality Management Director to ensure completion. The training record will be maintained in the personnel file.

Moving forward, The Social Services Coordinator will oversee the Consent and Human Rights Committee approval process to ensure there is no time laps in consents or approval. This will be done by obtaining consent and approval at the time of the Individual Support Planning meeting and again in October, at the time of the annual Human Rights Committee meeting. Consent and approval due during ISP meetings September to November will be obtained in July to ensure there is no lapse in consent.

The Program Director created a tracking grid to monitor when consent and approval is mailed to families and the HRC members. The tracking grid will also list the dates consent and approval is returned. The Social Services Coordinator will review the tracking grid two times a month for three months, then fade to two times a month for two months. Pending no errors are made in the consent and approval process, defined as following the procedures in this plan, the formal review will be documented for one additional month, then informally tracked by the Program Director each month during supervision meetings with the Social Services Coordinator.

The Program Director will assume the responsibilities outlined in the plan until a Social Services Coordinator is hired and trained.

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(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 ensure preventative medical care was provided for one of the two individuals in the original sample (Individual #1). The findings included:

A) Individual #1's record was reviewed on November 9, 2018. This review revealed a mammogram was performed on March 28, 2018. The report from this diagnostic test stated that Individual #1's right breast was not imaged. The report noted a marker in the left breast from a previous biopsy. In addition, it was recommended that a bilateral mammogram be performed in July 2018. There was no documentation in the record that this recommendation was followed up.

B) The director of nursing (DON) was interviewed on November 9, 2018, at 10:45 AM. The DON confirmed that the recommended bilateral mammogram for Individual #1 was not performed to date. In addition, the DON acknowledged that there was no documentation in Individual #1's record that follow-up was completed for this recommendation.






Plan of Correction:

W 0322 The facility must provide or obtain preventative and general medical care.
Individual #1's bilateral mammogram was performed on 10/31/2018. Results indicate both breasts were negative. Documentation was obtained and filed in her record.
The Director of Nursing will train the community nursing team on the importance of providing or obtaining preventative and general medical care. Training will focus on using a color coded calendar to document attended appointments, review of related paperwork, and follow up needed. The date of the follow up appointment will be added to the calendar on the date follow up is recommended, and on the date of the appointment. Training will include the requirement for the Health Services Coordinator to ensure the clinical reports from the provider are obtained and filed in the individual's record. This 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.

Beginning December 3, 2018 the Director of Nursing will request an update on all appointments by the Friday of that week. The Administrative LPN will color code the calendar based on the above categories within 24 hours of the appointment and document the outcome in the individuals Electronic Health Record.
After the first month, the Director of Nursing, or an assigned designee, will audit the calendar weekly, by each Friday. An appointment check audit form, developed by the Director of Nursing, will note the outcome of all appointments, including attended appointments, completed review of related paperwork, and the date of follow up appointments. The form will be signed by all reviewers and sent to the Program Director to be maintained in the plan of correction binder for the next twelve months.
After the first month, if the process is being followed correctly, defined as appointments made for all preventative and general medical care, the Director of Nursing, or an assigned designee, will check the calendar monthly. These appointment check audit forms will be filed at the Community Nurse office with documentation of the audits.
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(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 quarterly for the two individuals in the sample (Individuals #1, and #2). The findings included:

A) Individual #1
1) The record of Individual #1 was reviewed on November 9, 2018. This review revealed that there was no documentation of a quarterly nursing examination conducted during the month of October 2018.

2) The nurse was interviewed on November 9, 2018, at 9:10 AM. The nurse confirmed that Individual#1, did not have the benefit of a physical examination by a medical professional performed on a quarterly basis.

B) Individual #2

1) The record of Individual #2 was reviewed on November 7, 8, and 9, 2018. This review revealed that there was no documentation of a quarterly nursing examination conducted during the month April 2018.

2) The nurse was interviewed on November 9, 2018, at 8:45 AM. The nurse confirmed that Individuals# 2, did not have the benefit of a physical examination by a medical professional performed on a quarterly basis.




Plan of Correction:

366 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.