QA Investigation Results

Pennsylvania Department of Health
DON GUANELLA HOMES AT BETHEL
Health Inspection Results
DON GUANELLA HOMES AT BETHEL
Health Inspection Results For:


There are  8 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 monitor survey visit was conducted on October 10, 2018. The purpose of this visit was to determine compliance with the requirements of 42 CFR, Part 483, Subpart I regulations for Intermediate Care facilities for Individuals with intellectual disabilities. The census at the time of the survey was four, and the sample consisted of two Individuals.






Plan of Correction:




483.430(a) STANDARD
QIDP

Name - Component - 00
Each client's active treatment program must be integrated, coordinated and monitored by a qualified intellectual disability professional.

Observations:

Based on a review of facility incident report information and record review, it was determined that the Qualified Intellectual Disabilities Professional ( QIDP ) failed to integrate, coordinate and monitor active treatment programs for two of two sample Individuals.

Findings include:

- The facility failed to document data relative to the accomplishment of the criteria specified in the individual program plan objectives for two of two sample Individuals. This practice is specific to Individuals #1 and #2. Refer to W-252.

-The facility failed to provide a training program in the maintenance of oral health for two of two sample individuals with oral hygiene needs. This practice is specific to Individuals #1 and #2. Refer to W-350.

















Plan of Correction:

The Qualified Intellectual Disability Professional (QIDP) was retrained on the QIDP role of treatments programs to be integrated, coordinated and monitored by a QIDP, program documentation (data relative to accomplishment of criteria specified in individual program plan objectives) and training in relation to formal/informal education and training in the maintenance of oral health, by the Director of Community Programs. Completion date: 10/16/2018
All other QIDP's in the agency will be re-trained on the QIDP role of treatments programs to be integrated, coordinated and monitored by a QIDP, program documentation (data relative to accomplishment of criteria specified in individual program plan objectives) and training in relation to formal/informal education and training in the maintenance of oral health, by the Director of Social Service. Completion Date: 11/7/18
All new QIDP's to the agency through new employee orientation will include trainings on each individual's active treatment program being integrated, coordinated and monitored by a qualified Intellectual disability Professional, program documentation (data relative to accomplishment of criteria specified in individual program plan objectives) and training in relation to formal/informal education and training in the maintenance of oral health.
Completion date: ongoing

The QIDP will monitor treatment plans weekly to monitor frequency required by the plan to enable quantitative analysis of the individual's progress, for the next 3 months and then monthly thereafter by completing a goal review form and submitting to Director of Social Service. On a monthly basis, the QIDP documents a note to measure the qualitative analysis of the individual's progress on each treatment plan and the Program Director monitors the notes monthly for 3 months and quarterly thereafter and will report non-compliance to the administrator.
Completion date: ongoing

The trainings will be completed and documented on the QIDP orientation packet and copies will be submitted to the Director of Staff Training to become a part of the QIDP's training record. Completion date: ongoing
Persons Responsible; Program Director, Director of Social Services, Director of Community Programs, Administrator.




483.440(e)(1) STANDARD
PROGRAM DOCUMENTATION

Name - Component - 00
Data relative to accomplishment of the criteria specified in client individual program plan objectives must be documented in measurable terms.




Observations:

Based on record review, and interview with the qualified intellectual disability professional (QIDP), the facility failed to document data relative to the accomplishment of the criteria specified in the individual program plan objectives for two of two sample Individuals. This practice is specific to Individuals #1 and #2.

Findings include:

A review of two of two sample Individuals' records noted that in each of the individuals's training plans that were reviewed, there was a consistent lack of data documented in the frequency required by the plan to enable quantitative analysis of the individual's progress. An example of this practice includes the following:

1. A review of Individual #1's record revealed that this Individual currently has a training plan in place to learn how to select clean clothing for the day. This training plan was initiated on "9/12/" and revised on 02/09/2018. Currently, Individual #1 is on
step #1, to select a clean pair of underwear from his drawer for 6 of 8 sessions with
2 verbal prompts. This training plan designates that it should be documented two days a week, with a minimum of 12 documented sessions per month. A review of the data for the time period of June 1, 2018 through September 30, 2018 revealed that staff documented this program as follows:

June:6/2/2018, 6/9/2018
July7/7/2018, 7/19/2018
Aug.8/4/2018, 8/18/2018
Sept.9/1/2018, 9/15/2018, 9/22/2018, 9/29/2018


2. Individual #1 also has a training plan to increase his purchasing skills. This training plan was implemented on 03/16/2017 and revised 01/02/2018. Currently, Individual #1 is on step #2, to place the money in his pocket with 2 verbal prompts for 3 of 4 sessions. This training plan designates that it should be documented one time per week with a minimum of 4 documented sessions per month. A review of the data for the time period of June 1, 2018 through September 30, 2018 revealed that staff documented this training plan as follows:

June:6/2/2018, 6/9/2018
July7/7/2018
Aug.8/4/2018, 8/18/2018
Sept.9/1/2018, 9/15/2018, 9/22/2018, 9/29/2018

3. Indidual #1 also has a training plan to increase his self medication skills.
This training plan was implemented on 04/06/2015 and revised 01/01/2018.
Individual #1 is currently working on step #2, as noted on the March, 2018 data collection sheet, which states that Individual #1 will obtain the medication tray with
3 verbal prompts for 10 of 12 sessions. This training plan designates that it should be documented 3 time per week resulting in a minimum of 12 documented sessions per month. A review of the data for the time period of June 1, 2018 through
September 30, 2018 revealed that staff documented this program as follows:

June:6/15/2018, 6/25/2018, 6/29/2018
July7/4/2018, 7/6/2018, 7/9/2018, 7/11/2018, 7/13/2018, 7/16/2018, 7/20/2018
Aug.8/1/2018, 8/3/2018, 8/13/2018, 8/17/2018, 8/20/2018, 8/24/2018
Sept.no data sheet available for review


Interview with the QIDP on 10/10/2018 at approximately 11:15 AM acknowledged that there was a lack of consistent documentation for the training plans as outlined within the plan structure. This interviewee was unable to indicate what revisions were implemented to ensure that data collection wad completed as outlined.




























Plan of Correction:

The QIDP held team meetings for Individuals #1 and #2, to review all Individuals Program Plans, (IPP) to ensure all priority needs are reflected in goal plan implementation/training programs and written in measurable terms to accomplish the specified criteria in each program plan through the documented data.
Completion date: 10/16/18
The QIDP held team meetings for all other individuals that reside in the home, to review all Individuals Program Plans, (IPP) to ensure all priority needs are reflected in goal plan implementation/training programs and written in measurable terms to accomplish the specified criteria in each program plan through the documented data.
Completion date: 10/16/18
All Direct Support Professionals (DSP) and Assistant House Manager (AHM) were re-trained on the implementation methods and frequency of all IPP goal plans/new goal plans for Individuals #1, #2 and all other individuals that reside in the home by the QIDP. As revisions occur within the IPP year for goal plans and frequency required by the plan to enable quantitative analysis of the individual's progress, training will be implemented for all DSP's and AHM within 1 week of the revision. The QIDP created a weekly calendar for all individuals which will be used by staff showing the specific goals, number of times implemented per week and days of week to occur. As revisions occur, the weekly calendar will be revised by the QIDP. All training sheets will be kept on file in the home and originals forwarded to the Director of staff training to be documented in the employees training record.
Completion date: 10/23/18 & ongoing
The QIDP will monitor goal implementation weekly to monitor frequency required by the plan to enable quantitative analysis of the individual's progress, for the next 3 months and then monthly thereafter by completing a goal review form and submitting to Director of Social Service. On a monthly basis, the QIDP documents a note to measure the qualitative analysis of the individual's progress and the Program Director monitors the notes monthly for 3 months and quarterly thereafter and will report non-compliance to the administrator.
Completion date: 1/31/2019
The AHM will be trained by Residential Coordinator to complete a daily goal compliance report via the care tracker electronic system for the next 12 months. The compliance report will be included in the daily report. All training sheets will be kept on file in the home and originals forwarded to the Director of staff training to be documented in the employees training record.
Completion Date: 10/31/2019
The Residential Coordinator will complete a weekly goal compliance report to monitor frequency required by the plan to enable quantitative analysis of the individual's progress for the next 3 months and monthly thereafter and submit the report to the Director of Community Programs.
Completion date: 1/31/2019
The Director of Community programs will review data collection monthly to monitor frequency required by the plan to enable quantitative analysis of the individual's progress for next three months and quarterly thereafter. These reports and any findings will be submitted to Administrator for any needed corrective actions.
Responsible parties: DSP's, QIDP, AHM, Residential Coordinator, Program Director, Director of Social Services, Director of Community Programs and Administrator



483.460(e)(3) STANDARD
DENTAL SERVICES

Name - Component - 00
The facility must provide education and training in the maintenance of oral health.



Observations:


Based on record review and interview with the qualified intellectual disabilities professional (QIDP), the facility failed to provide a training program in the maintenance of oral health for two of two sample Individuals with oral hygiene needs. This practice is specific to Individuals #1 and #2.

Findings include:

A review of two of two sample Individuals' records noted that in each of the individuals's training plans that were reviewed,that despite designated needs noted by a dentist for increased oral hygiene skills, there was no oral hygiene training plan in place to address this need. An example of this practice includes the following:

1. A review of Individual #1's record revealed a dental report dated 08/16/2018. This dental report documented that this Individual has mild to moderate periodontitis,
7 missing teeth, and heavy calculus.

Continued review of the record revealed that this Individual previously had a training plan in place to address increased dental hygiene skills and compliance which was discontinued on or about 07/09/2018. However, in further review, there was no
information designating why the training plan had been discontinued, nor an alternate training plan in place to address this needs as designated in dental report.

Further review revealed that there is no current oral hygiene training program available to this individual as of the date of this survey.

Interview with the QIDP on 10/10/2018 at approximately 11:30 AM confirmed that although this individual as identified needs in oral hygiene, Individual #1 does not have a formal or informal training program to address these need.































Plan of Correction:

The QIDP held team meetings for Individuals #1 and #2, to review Individuals Program Plans, (IPP) to ensure all priority needs are reflected in goal plan implementation/training programs to promote acquisition of skills and maintenance of health related needs, specifically dental health.
Completion date: 10/16/18
The QIDP held team meetings for all other individuals that reside in the home, to review all Individuals Program Plans, (IPP) to ensure all priority needs are reflected in goal plan implementation/training programs to promote acquisition of skills and maintenance of health related needs, specifically dental health.
Completion date: 10/16/18
All dental consults should be forwarded from Health Care Coordinator (HCC) or nurse to the QIDP and team within 7 days of dental appointment. The QIDP will be responsible to conduct a team meeting to review results and create an appropriate dental hygiene plan. Plans should be implemented with 14 days of team meeting. On a monthly basis, the QIDP documents a note to measure the qualitative analysis of the individual's progress and the Program Director monitors the notes monthly for 3 months and quarterly thereafter and will report non-compliance to the administrator.
Completion date: on-going
Within 14 days of team meetings, any new goal or revised goal plan must be written, trained and implemented by the Qualified Intellectual Disability Professional (QIDP). The QIDP will provide training to all direct care staff, Assistant House Manager (AHM), and Residential Coordinator.
Completion date: 10/29/2018
All Direct Support Professionals (DSP) and Assistant House Manager (AHM) were re-trained on the implementation methods and frequency of all IPP goal plans/new goal plans for Individuals #1, #2 and all other individuals that reside in the home by the QIDP. As revisions occur within the IPP year for goal plans and frequency required by the plan to enable quantitative analysis of the individual's progress, training will be implemented for all DSP's and AHM within 1 week of the revision. The QIDP created a weekly calendar for all individuals which will be used by staff showing the specific goals, number of times implemented per week and days of week to occur. As revisions occur, the weekly calendar will be revised by the QIDP. All training sheets will be kept on file in the home and originals forwarded to the Director of staff training to be documented in the employees training record.
Completion date: 10/23/18 & ongoing
The QIDP will monitor goal implementation weekly to monitor frequency required by the plan to enable quantitative analysis of the individual's progress, for the next 3 months and then monthly thereafter by completing a goal review form and submitting to Director of Social Service.
Completion date: 1/31/2019
The AHM will be trained by Residential Coordinator to complete a daily goal compliance report via the care tracker electronic system for the next 12 months. The compliance report will be included in the daily report. All training sheets will be kept on file in the home and originals forwarded to the Director of staff training to be documented in the employees training record.
Completion Date: 10/31/2019
The Residential Coordinator will complete a weekly goal compliance report to monitor frequency required by the plan to enable quantitative analysis of the individual's progress for the next 3 months and monthly thereafter and submit the report to the Director of Community Programs.
Completion date: 1/31/2019
The Director of Community programs will review data collection monthly to monitor frequency required by the plan to enable quantitative analysis of the individual's progress for next three months and quarterly thereafter. These reports and any findings will be submitted to Administrator for any needed corrective actions.
Responsible parties: DSP's, QIDP, AHM, Residential Coordinator, Health Care Coordinator, Program Director, Director of Social Services, Director of Community Programs and Administrator