There are  29 surveys for this facility. Please select a date to view the survey results.

The governing body will provide, monitor, and revise, as necessary, policies and operating directions which ensure the necessary staffing, training, resources, equipment and environment to provide for each Individuals' health and safety.

As per the governing body, the Program Director will train the Program Coordinator and all Qualified Intellectually Disabled Professional Supervisors on the facility policy Disciplinary Guidelines, which states, "every PA Adult Services employee has an obligation to observe and follow PA Adult Service's policies and procedures, and to maintain proper standards of conduct at all times. If an individual's behavior interferes with the orderly and efficient operation of a department, corrective disciplinary measures will be taken." Per policy, reasons for disciplinary measures, which may result in termination for cause, includes falsification of records and dishonesty. Training will include the facility policy Fire Drills, which states that PA Adult Services will make certain that fire drills are completed for each facility/program on a monthly basis. The time of day for fire drills will be in accordance with the Center's fire drill schedule. The facility Fire Drill Schedule, created by the Program Director, will be reviewed during this training. Training will include action steps to take when a fire drill cannot be completed as scheduled, which includes conducting a make-up drill to meet the requirements for the day, shift, and time of incomplete drill. Training will be completed by February 15, 2025, will be documented on a training form, and will be kept in the employee's People Operations file. The training will be forwarded to the Quality Management Director, who will document confirmed completion.

As per the governing body, the Program Director will participate in a meeting with the QIDP Supervisor and the People Operations Director to discuss the falsified document. This meeting took place January 28, 2025. Following the meeting, identified preventative corrective measures will be implemented. The Program Director will implement preventative corrective measures by February 15, 2025, documented on an agency approved from, and forward to the Director of People Operations, who will document confirmed completion. Documentation will be kept in the employee's People Operations file.

As per the governing body, the Program Director will confirm that fire drill documentation is accurate and not falsified. The Program Director discussed the need for a fire system report, generated one time per month, with alarm monitoring company on January 28, 2025. It was confirmed that a report documenting the Fire Drill procedure conducted by the facility will be sent electronically to the Program Director for review one time per month, starting February 2025. The Program Director will compare the report to the Fire Drill paperwork to assure the information is accurate and not falsified. The Program Director will document her review by highlighting documentation of the drill, and signing and dating the report. The report will be maintained by the Program Director. If there is evidence that the fire drill was falsified, the staff responsible for falsification will receive progressive disciplinary actions, which may include employment termination and a fire drill will be completed, run by the Program Coordinator.

If the report is not generated and emailed to the Program Director, the Program Director will call the alarm monitoring company to obtain confirmation that there is evidence that a Fire Drill was implemented. Documentation of the date and time of the call, as well as any reference number or code, will be written on the Fire Drill form by the Program Director, and maintained by the Program Director.

For the first four months, February to May 2025, the Program Director will call the alarm monitoring company for verbal documentation of the fire drill, within 72 hours of the drill, to assure it was completed as scheduled. If there are no concerns, meaning no drills were falsified, the Program Director will fade to reviewing the report sent by the alarm monitoring company for the next two months, June and July 2025. Documentation of all reviews will be as stated. August and onward, the Program Director will review the report two times per year, and address any concerns immediately. Documenation will be as stated.

The Program Director will review the fire alarm report, sent by the alarm monitoring company, each month, starting February 2025, to assure there is evidence that a fire drill was completed for all other Intermediate Care Facilities facilities, documenting he review as stated. This review will take place for four months, and if there are no concerns, fade to documenting a review two times per quarter, and address any concerns immediately.

The Program Director will create a tracking grid for all tasks outlined in this plan of correction. The Program Director will review the updated tracking grid after each target date for completion, and forward to the Quality Management Director, who will document confirmed completion. The tracking grid will be maintained in a Plan of Corrections 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.

The Director of Nursing (DON) will train the Health Services Coordinator (HSC) on the importance of providing or obtaining preventative and general medical care. This training will focus on the importance of following recommendations to seek follow up care and preventative health care in a timely manner. Training will include verifying prescription orders that are provided by specialist with primary physicians, then obtain verbal orders from the primary physicians and update monthly orders with interim and new orders. Further, once recommendations are obtained, physician's orders will be obtained immediately, as applicable, to prevent a delay in services. Training will be completed by February 15, 2025. The Program Director will sign to ensure completion. The training record will be kept in the employee's People Operations file.

Lab access was requested from the previous contracted lab used during 2024, and ADL and ordered labs were requested for Individual #1. Lab results were received for 2023 and 2024. Audits of all individuals in the facility are being done by the Health Services Coordinator, or designee, documented on a form approved by the Director of Nursing, and the review is to be completed by February 15, 2025. The review will verify completion of labs as per physician orders. The Director of Nursing will provide documentation confirming completion.

Individual #1 was evaluated by the physician with ordered labs on January 8, 2025 and January 29 2025. The next set of labs are ordered to be done by April 11, 2025 based on the current physician orders.

Individual #2 had a neurology appointment on January 8, 2025. Documentation indicates he is stable. Documentation was sent to the Interdisciplinary Team by the Qualified Intellectually Disabled Professional on January 8, 2025 and will be added to his Electronic Health Record.

An audit is to be done of all appointments that were scheduled in the facility for all individuals. Documentation is being reviewed for the reason of any identified missed appointment. This is to be completed by the Health Services Coordinator, or designee, by February 15, 2025. If there are any missed appointments identified, there will be immediate documentation required by the Health Services Coordinator and this will be reported to the Nurse Manager. An appointment will be rescheduled by ICF Administrative Support if there is not already a rescheduled appointment. The Director of Nursing will initiate a meeting with Health Services Coordinator and facility Supervisory team regarding the prevention of missed medical appointments, and the importance of documenting missed medical appointments in the Electronic Health Record. This meeting will occur by February 15, 2025. Documentation of attendance will be on a signature sheet, and sent to the Program Director to confirm completion.

There will be ongoing monthly audits of medical appointments by the ICF Administrative Support Staff. All concerns noted will be communicated to the Health Services Coordinator and other members of the Nursing and/or Supervisory team.

On a weekly basis for the next six months the Health Services Coordinator and the Administrative Assistant will review the tracking tool for appointment attendance compliance and lab testing compliance and submit their findings to the Director of Nursing and the Community Nurse Manager by Friday of every week. Missed labwork and other missed tests and/or appointments will be rescheduled immediately. The Nurse Manager will document their review by signing and dating the tracking tool by the beginning of the following week and sending the information to the Program Director. This plan will be implemented beginning January 31, 2025.

For the next six months, the Community Nurse Manager, or designee, will meet with the Health Services Coordinator every month to review medical appointments and corresponding documentation including physician orders to ensure that there is appropriate documentation following each appointment, results of all specialized studies have been obtained, all recommendations for follow-up treatment have been followed, and follow up appointments have been made appropriately. Any deficiency identified will require immediate notification to the Director of Nursing and the Program Director. Immediate notification will need to be made to the physician if warranted and documentation in the EHR on the corrective action will be made. On a monthly basis, the Director of Nursing or designee will conduct a random audit of selected charts to ensure compliance. Documentation of this review will be submitted to the Program Director and Assistant Executive Director.

Failure to follow the steps outlined in this plan of correction will lead to re-training and the policy for progressive discipline will be take effect.

Plan of Correction 104 includes measures taken by the Health Services Coordinator to report errors to the Primary Care Physician and obtain orders as to how to proceed. It also includes preventative corrective measures for the Direct Support Professional Staff who is responsible for the errors.

The Director of Nursing will conduct retraining for the Health Services Coordinator on the importance of providing clients with nursing services in accordance with their need. Training will include expectations and procedures for nursing services related to medication administration. This training will emphasize the importance of reviewing the Medication Administration Record (MAR), communicating with staff, documenting findings in the Electronic Health Record (EHR), and notifying the Interdisciplinary Team via email. Training will include facility Policy 208-7 Medications with Attachments which states that the Program Supervisor/Coordinator will work with the Health Services Coordinator and staff certified to administer medications to ensure Medication Administration Records (MARs) are accurate when received from the pharmacy, MARs are completed at the time of each administration, MARs are collected and reviewed at least monthly, and proper and accurate administration of medications via direct observation and feedback/training/counseling as needed. Per facility policy, at least monthly, the residential supervisor/coordinator/HSC or designee will check each MAR for completeness and accuracy and also check the storage and accessibility of all medications to ensure compliance. Training will be completed by February 15, 2025, signed by the Director of Nursing, and forwarded to the Program Director to confirm completion. Training records are maintained by the people Operations Department.
The Director of Nursing, or designee, will provide feedback to the Pharmacy Manager in regards to the July MAR not having all of the times of administration for Individual #3's Polyvinal Alcohol Solution. The Director of Nursing will summarize her feedback in an email to the Pharmacy Manager, and pertinent people. Emailed communication will be initiated by February 15, 2025 and will be forwarded to the Quality Management Director and Director of Nursing to confirm completion. Emailed communication will be added to the investigation file. Moving forward, the Health Services Coordinator will alert the Director of Nursing of any pharmacy errors on the MAR so feedback can be provided, following the identified process.
The Director of Nursing, or designee, will provide feedback to the Pharmacy Reviewer who reviewed Individual #3's MAR for July and August, and did not identify the medication errors. Training will include the importance of reviewing to determine whether to facility is in compliance in the areas assuring the MAR matches the physician orders, and discontinued medications are reflected on the MAR and physician orders. The Director of Nursing will summarize her feedback in an email to the Reviewer, and pertinent people. Emailed communication will be initiated by February 15, 2025 and will be forwarded to the Quality Management Director and Director of Nursing to confirm completion. Emailed communication will be added to the investigation file.
The Health Services Coordinator and Community Nurse Manager will conduct a comprehensive review of all individuals MAR and physician orders, as well as all other records, by February 15, 2025. This review will ensure that nursing services are aligned with each person's needs, and any concerns and action steps can be identified and taken. The Director of Nursing will identify a form used to record findings and action steps needed, and will be signed and dated by the Health Services Coordinator and Community Nurse Manager. The Director of Nursing will assure completion.
For the next six months, the Community Nurse Manager (or designee) will be informed of any medication changes within the facility by the Health Services Coordinator. The Community Nurse Manager will review the EHR and communicate with the Health Services Coordinator to verify proper follow-up, as per facility Policy Medications with Attachments. A report will be sent to the Director of Nursing, and these communications will be filed by the Director of Nursing and sent to the Program Director for inclusion in the Plan of Correction file.
If no deficiencies are identified after six months, this plan will be discontinued. However, if deficiencies are noted, the plan will continue for an additional six months. Each deficiency will result in an extension of the monitoring period. The Director of Nursing and Community Nurse Manager will review the electronic files during their monthly 1:1 meetings.
Taking these actions will assure that nursing services are consistently provided in accordance with individual needs, and assure that corrective measures are implemented and tracked appropriately. 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.

The facility has implemented plans of correction for each identified neglect allegation related to medication management. In each incident, the nurse was immediately contacted, unless they discovered the incident. The nurse immediately contacted the Primary Care Physician in effort to report the error obtain an order as to how to proceed. This was reviewed during the survey for each individual, and no concerns were noted. Also, a clinical consultation was requested, and completed, to assure there were no lingering negative effects from the incidents. Additional, specific, preventative corrective measures are described below:

In regards to Individual #3:
1. Omission of Artificial Tears, Eucerin, Chlorhex, NEO/POLY/DEX on January 24, 2024, at 7:00am:
a. (Completed 1/30/24) The staff responsible was identified and received retraining on the facility policy Medications with Attachments and progressive disciplinary action was administered.
2. Omission of Lactase on January 25, 2024, at 7:00am:
a. (Completed 2/8/24) The staff responsible was identified and received retraining on the facility policy Medications with Attachments and progressive disciplinary action was administered.
3. Omission of Polyvinyl Eye Solution from June 7, 2024 - June 30, 2024, Omission of four times daily Polyvinyl Eye Solution from July 1, 2024 - August 15, 2024, and Administered discontinued Artificial Tears from July 1, 2024 - August 15, 2024:
a. (Completed by 9/15/24) Disciplinary action, in addition to retraining, administered to each target.
b. (In progress) the Director of Nursing will review the incident, and the role Quality Health Pharmacy played with the Pharmacy Manager and request that the Pharmacy Manage identify and implement preventive corrective actions to assure that all times for medication administration are consistently printed on the MAR. The Director of Nursing, or designee, will provide feedback to the Pharmacy Manager in regards to the July MAR not having all of the times of administration for Individual #3's Polyvinal Alcohol Solution. The Director of Nursing will summarize her feedback in an email to the Pharmacy Manager, and pertinent people. Emailed communication will be initiated by February 15, 2025 and will be forwarded to the Quality Management Director and Director of Nursing to confirm completion. Emailed communication will be added to the investigation file. Moving forward, the Health Services Coordinator will alert the Director of Nursing of any pharmacy errors on the MAR so feedback can be provided, following the identified process.
c. (In progress) Retraining by the Director of Nursing for the Nurses preparing the MARs to assure that they are comparing it to the current MAR and current physician orders to identify discrepancies and assure the MAR is properly prepared prior to the start of the month. Training will be completed by February 15, 2025, signed by the Director of Nursing, and forwarded to the Program Director to confirm completion. Training records are maintained by the people Operations Department.
d. (In Progress) Retraining for the Coordinator and Supervisor on the importance of carefully reviewing the MAR to assure there is a medication time printed that corresponds to each administration time, when completing the Weekly Supervisor Medication Checks. This is related to the question, "Do medication labels match MAR?". Training will be completed by the Program Director by February 15, 2025 and forward to the Quality Management Director to confirm completion. Training records are maintained by the people Operations Department.
4. Wrong date and wrong time of F&T ear wax removal drops from July 4, 2024 to July 25, 2024:
a. (Requested 8/20/24) Retraining for the Health Services Coordinator for failure to report the incident to a live person. Upon review on 1/31/25 documentation there is no documentation of training completion. The Program Director requested training again on 1/31/25 by the Director of Nursing, no later then 2/15/25. Documentation will be forwarded to the Program Director to confirm completion, and to the Certified Investigator to be added to the investigation file.
b. (Employment terminated prior to completion) On-Call Supervisor will retake the full Medication Administration Standard Student Course. Retraining and disciplinary action related to late EIM incident reporting will be administered:
c. (Completed 7/30/24) The Program Director met with the On-Call Supervisor as an additional training measure. The importance of adhering to reporting timeframes was reviewed again. On 8/1/24 the Supervisor was instructed to attend the full, formal, EIM Training Session again, in effort to solidify learning, however his employment was terminated prior to completion.
d. (Completed by 9/15/24) Disciplinary action, in addition to retraining, administered to each target.
e. (Completed 9/3/24) The Supervisor will receive disciplinary action in addition to retraining. The Supervisor had several medication neglect incidents in his two homes. As preventative corrective measures, on 3/5/24 he received a long and detailed training of policy 208-7d by the Program Director. Training included a detailed review of supervisory and staff responsibilities for medication oversight, and each form. Many examples for successful medication management were reviewed.
f. (Completed 4/3/24) The Supervisor was required to attend and successfully pass the Medication Administration Standard Student Course.
g. (Completed by 9/3/24) Retraining for the Administrative Supervisor and facility staff.
h. (Completed 8/2/24) The Supervisor was asked to complete the Weekly Supervisor Check for each of his two homes, and email the results to the Coordinator and Director. This was done, and both reports indicate no concerns noted.
i. (Completed 8/2/24) Each month during the 1:1 meeting the Program Director discusses the importance of collecting Weekly Supervisor Medication Checks with the Program Coordinator. The Director demonstrated how to develop a tracking grid for Supervisory paperwork compliance and the Coordinator was receptive to updating and emailing it out one time per week, each Friday, in effort to better track and follow up with missing documentation. This was instituted 8/2/24.
5. Omission of twice daily Docusate Sodium\Colace from July 26, 2024 - July 29, 2024:
a. (Employee terminated prior to completion) Retaining for the On-Call Supervisor and back up On-Call Supervisor in regards to the importance of immediately reporting all incidents to the Program Director. (It was determined that the back-up On-Call supervisor was not responsible for not reporting this incident)
b. (Employment terminated prior to completion) The On-Call Supervisor will retake the full Medication Administration Standard Student Course. Retraining and disciplinary action related to late EIM incident reporting will be administered:
c. (Completed 7/29/24) Retraining for Quality Health Pharmacy Staff: Per the Quality Health Pharmacy Manager, the medication was not sent to the home due to a system error; the auto-renew did not show up. The Pharmacy Manager indicated she had a meeting with her team and reviewed the incident on 7/29/24. She retrained her team on how to enter tickler notifications into the system, which assures medication is automatically refilled. The Pharmacy Manager processed the refill and scheduled it for delivery to Spruce in time for the Individual to receive the 8p dose 7/29/24.
d. (Completed by 11/20/24) Administer disciplinary action for the Supervisor and DSP staff responsible for this error.
e. (Completed 4/3/24) The Supervisor was required to attend and successfully pass the full Medication Administration classroom training.

In regards to Individual #4:
1. Omission of Clonazepam on September 2, 2024, at 8:00am.
a. (Completed 11/22/24) The staff responsible was identified and received retraining on the facility policy Medications with Attachments and progressive disciplinary action was administered.

In regards to Individual #5
1. Omission/ late administration of Levothyroxine on January 25, 2024, at 7:30am:
a. (Completed 2/8/24) The staff responsible was identified and received retraining on the facility policy Medications with Attachments and progressive disciplinary action was administered.

The record of Individual #1 and #3 were reviewed during the time of the survey and there were no incidents of medication errors or neglect related to medication management during the timeframe surveyed.

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.

The Program Coordinator will train the Supervisor and all Direct Support Professional staff on the importance of ensuring that that all drugs, including those that are self-administered, are administered without error. The training will include comparing all medication pharmacy labels to the Medication Administration Record to assure medications are administered as per the 5 Rights, such as the correct route and specialized instructions, such as administering required medications 30 minutes before breakfast, as ordered. This review will assure that all medications ordered to be administered at a specific are administered at that time. The training will be completed by February 21, 2025. Training will include Policy Medications with Attachments that focuses on the importance of ensuring that all drugs are administered without error. The Program Director will sign and date the trainings to confirm completion. The Program Coordinator will ensure all Direct Support Professional staff are trained by comparing completed training records with the staff schedule. Training records will be maintained in the personnel files.
Following the medication errors for Individual #3, the nurse was consulted, and it was requested that she consult the Primary Care Physician for a verbal order as to how to proceed. A verbal order was obtained on January 14, 2025. The order for individual #3' Beano and Lactose instructs staff to skip the missed dose and continue with scheduled medication as ordered. The order for fluocinonide indicates staff should continue with the scheduled cream as ordered, monitor individual, and report any abnormalities around the eyes. No abnormalities were observed or reported as a result of this medication error.
On January 28, 2025 it was noted that the verbal order for Individual #3's omission of Maxitrol eye ointment and Polyvinyl Alcohol 1.4% eye drops was not included in the verbal orders obtained. The Health Services Coordinator was notified, and immediately contact the Primary Care Physician to report the error. A verbal order was obtained on January 28, 2025 and instructs staff to continue with scheduled eye drops/medications as ordered. As a preventative corrective measure for the late reporting, the Director of Nursing will train the Health Services Coordinator to immediately report medication errors to the Primary Care Physician and obtain orders as to how to proceed. Training will include the importance of the Health Services Coordinator refencing the Individuals Electronic Health Record to assure the report and verbal orders cover all medications that were administered in error. Training will be completed by February 15, 2025, emailed to the Program Director to confirm completion, and maintained in personnel files.
A supervisory team member will conduct unannounced observations, at varied medication administration times, to ensure that all medication is administered without error which includes reviewing the 5 Rights, following special instruction and confirming all medications ordered are administered. Observations will be recorded on a tracking grid developed by the Program Director and will specify whether the medication is administered without error. These observations will begin February 21, 2025 and all Direct Support Professional staff will be observed at least two times by March 15, 2025. If staff does not ensure medication is administered without error, the staff member making the error will continue to be observed at least two times every two weeks until there are two successful observations, defined by administering all medication without error.
After two successful observations the monitoring will be faded to one additional time by March 31, 2025, then two times per year and conducted during the time of each staff member's semi-annual medication administration training. If 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.
Observations through March 31, 2025 will be recorded on the tracking grid developed by the Program Director 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 Program Coordinator will ensure compliance by reviewing, signing, and dating the tracking grid.
The Learning Program Assistant will track annual training requirements to assure 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 Direct Support Professional 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.

440 The facility must hold evacuation drills at least quarterly for each shift of personnel.

The Program Coordinator will train the Supervisor to hold evacuation drills at least quarterly for each shift of personnel. Training will focus on ensuring evacuation drills are held on each of the three shifts each quarter of the calendar year, including 3rd shift. Training will include a review of the Fire Drill Schedule for the remainder of 2025, developed by the Program Director, to assist in assuring compliance. Training will take place by February 8, 2025 and the Program Director will sign and date the training to assure completion. Training records will be maintained in the personnel files.

The Program Coordinator will monitor monthly fire drills on an ongoing basis to ensure drills are held at least quarterly for each shift of personnel, according to the schedule.

Immediately following the drill, the Supervisor will send a text message the Program Coordinator confirming the drill was completed, and the time it took to evacuate the home. Within 72 hours of a fire drill, the Supervisor will scan and email the designated documentation paperwork to the Quality Management Specialist, Program Coordinator, and Program Director who will review fire drills and monitor to ensure they are being done as per the schedule. If the drill is not preformed according to the schedule, another drill will be held that quarter at the specified time, as per the schedule. For the next 6 months, the Program Coordinator, or designee, will respond to the e-mail documenting her review, and documenting whether or not another drill needs to be conducted. Fire drill reports will be maintained at the facility. The Program Coordinator will maintain documentation of all email threads electronically.

If there are no problems noted, moving forward the Program Coordinator will still monitor the drills to assure drills are done at least quarterly for each shift of personnel however the Program Coordinator may only respond if problems are noted. The Quality Management Specialist will oversee reviewing the fire drill report and providing feedback if corrective actions are needed. The Quality Management Specialist may only respond if problems are noted.

Failure to follow the steps outlined in this plan of correction will lead to re-training and the policy for progressive discipline will be take effect.