QA Investigation Results

Pennsylvania Department of Health
FRIENDSHIP COMMUNITY WEST ORANGE STREET
Health Inspection Results
FRIENDSHIP COMMUNITY WEST ORANGE STREET
Health Inspection Results For:


There are  21 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:

A focused fundamental survey was conducted March 12 - 13, 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 four and the sample consisted of two individuals. Three deficiencies were identified.





Plan of Correction:




483.420(d)(3) STANDARD
STAFF TREATMENT OF CLIENTS

Name - Component - 00
The facility must prevent further potential abuse while the investigation is in progress.



Observations:

Based on documentation review and staff interview, it was determined that the facility failed to ensure that individuals at the facility were protected from potential reoccurrence of neglect. The findings included:

A) Investigations for the past year were reviewed on March 12, 2019. This review revealed one investigation into an accident which lead to an emergency room visit. This incident occurred on October 26, 2018, at approximately 3:30 PM. A staff member failed to return the wheelchair lift on the van to the "up position." This failure to implement protocol lead to an individual being sent to the emergency room. No injuries were noted.

The investigation packet did not contain documentation that the target was immediately removed from client contact.

B) The associate director of operations (ADOP) was interviewed on March 12, 2019, at 10:00 AM. The ADOP confirmed that the facility did not remove the target from individual contact. On March 13, 2019, the qualified intellectual disabilities professional provided timecards which verified that the target was not removed until October 29, 2018.








Plan of Correction:

Lead CI/Associate Director of Operations shall develop and implement a system of communication and documentation (Immediate Action and Safety Plan) regarding measures taken to immediately protect all Individuals from further potential abuse at the onset of an incident, on or before 3/29/19. The Immediate Action and Safety Plan shall include details regarding immediate target removal from Individual contact, as required per regulations/incident category. This new system of communication and documentation shall be trained by Lead CI/Associate Director of Operations to each Leader within the organization responsible for managing incidents and ensuring safety on behalf of Individuals on or before April, 1, 2019 and documentation of training shall be kept on file. Lead CI/Associate Director of Operations or designee will assign the Immediate Action and Safety Plan upon discovery of incidents/assignment of Certified Investigation to the Program Coordinator or designee, as applicable per regulations and incident management guidelines. Program Coordinators shall ensure the Immediate Action and Safety Plan is completed and documented immediately following discovery of each incident on behalf of all Individuals served within the program. Each Immediate Action and Safety Plan document shall be shared with the Lead CI/Associate Director of Operations (or designee) within 24 hours of incident discovery, to be reviewed for assurance that adequate implementation of safety measures on behalf of Individuals has occurred. Immediate Action and Safety Plan for each Certified Investigation will also be reviewed and monitored at the Administrative Review for the alleged incident as an additional measure of oversight by members of Administration. Additionally, each Leader within the organization responsible for managing incidents and ensuring safety on behalf of Individuals shall review Incident Management guidelines outlined in the organization's policy and procedure manual on or before April 1, 2019 and documentation of this review shall be kept on file.


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 cleaning supplies and poisons were locked, consistent with an individual's program plan (IPP). This was noted for one individual in the home (Individual #3). The findings included:

A) A physical plant inspection was conducted on March 13, 2019, between 11:00 AM and 11:35 AM. The qualified intellectual disabilities professional (QIDP) and program manager (PM) accompanied the surveyors during the inspection.

B) During the inspection, the surveyor inquired about a set of keys hanging on the wall outside of a bathroom closet within Individual #3's bedroom. The QIDP stated these keys were for a locked box of cleaning supplies inside the closet. The surveyor located the box of cleaning supplies on the closet floor and discovered it was not locked.

C) The QIDP was interviewed at the time of discovery and confirmed that the box of cleaning supplies should be kept locked when not in use, as indicated in Individual #3's IPP and consents.






Plan of Correction:

The QIDP and Program Manager ensured all cleaning supplies, chemicals and poisons are inaccessible to Individual #3, per Individual's Program Plan (IPP), immediately upon discovery that they were not inaccessible on 3/13/19 during the physical site walk through completed by inspectors. On 3/13/19 the QIDP provided a retraining memo for Team Members to ensure that all chemicals and poisons are inaccessible to Individuals. The Program Manager will verify each Team Member 's acknowledgement of the retraining memo on or before 4/1/19. Beginning in April 2019, the QIDP will complete a random check at least once a month, throughout the next 12 months, to ensure compliance in this area on behalf of all Individuals in the program, and shall document findings on a monitoring form. Documentation of monitoring on at a least a monthly basis as completed by the QIDP shall be kept on file and reviewed by the Associate Director of Operations to ensure completion within 2 working days following completion of each monthly monitoring for a period of 12 months, beginning in April 2019. On 3/18/19 the QIDP created a tracking system to be acknowledged and implemented by Team Members on each shift, verifying that all cleaning supplies, chemicals, and poisons are inaccessible to each Individual, as specified in each Individual's IPP, which shall serve as a per-shift reminder to ensure that they have properly secured all poisonous chemicals. On 3/18/19 the Program Manager provided training to Team Members, explaining the function of the tracking system and need to maintain compliance in this area for the safety of all Individuals. Program Manager will monitor the tracking system at least monthly to ensure the daily compliance of all Team Members.


483.470(i)(1) STANDARD
EVACUATION DRILLS

Name - Component - 00
The facility must hold evacuation drills under varied conditions.



Observations:

Based on documentation review and staff interview, it was determined that the facility failed to conduct evacuation drills at varied times. The findings included:

A) The evacuation drill reports for the past year were reviewed on March 12, 2019. This review revealed the following:

1. Two of the four first shift drills were conducted between 7:15 AM and 7:50 AM.

2. Two of the four second shift drills were conducted between 3:45 PM and 4:00 PM.

B) The qualified intellectual disabilities professional (QIDP) was interviewed on March 12, 2019, at 8:55 AM. The QIDP acknowledged that the drills were conducted in clusters of time for the first and second shifts of personnel.






Plan of Correction:

On 3/13/19, Director of Operations provided retraining to the Associate Director of Operations regarding the requirement to ensure that fire evacuation schedules adhere to the guidelines as specified in regulations regarding varied times, days and locations of drills. On 3/13/19, QIDP and the Associate Director of Operations implemented a more specific timeframe guideline to follow in developing fire evacuation drill schedules, limiting the timeframe for the completion of each drill to a one-hour timespan, which will allow for more specificity in ensuring that each drill throughout the year occurs at varied times as required by regulations. The evacuation drill schedule for 2019/2020 was reviewed for compliance with revised by QIDP and Program Manager on 3/19/19 to provide more defined variations in scheduling of evacuation drills throughout the next 12 months. Associate Director of Operations and Director of Operations verified on 3/19/19 that the 2019/2020 evacuation drill schedule appropriately captures varied times, days and locations of evacuation drills throughout the next 12 months. Upon completion of each month's evacuation drill, QIDP and Associate Director of Operations shall compare the drill with the 2019/2020 evacuation drill schedule within 2 working days to ensure that drills are conducted at varied times, days and locations throughout the next 12 months. During monthly monitoring the QIDP will ensure that the evacuation drills are conducted under varied times and conditions and that the Program Manager and/or designee are utilizing the evacuation drill schedule. Documentation of monitoring on at a least a monthly basis as completed by the QIDP shall be kept on file and reviewed by the Associate Director of Operations to ensure completion within 2 working days following completion of each monthly monitoring for a period of 12 months, beginning in April 2019.