QA Investigation Results

Pennsylvania Department of Health
EBENSBURG CENTER
Health Inspection Results
EBENSBURG CENTER
Health Inspection Results For:


There are  54 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 3, 2021 through March 15, 2021 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 182, and the sample consisted of 15 individuals. Three deficiencies were identified as a result of the survey.


Plan of Correction:




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

Name - Component - 00
The facility must have evidence that all alleged violations are thoroughly investigated.



Observations:

Based on investigation report review and staff interview, it was determined that the facility failed to thoroughly investigate harmful behavior of one individual (Individual #1).

The findings included:

A. The facility's investigation into Individual #1's harmful behavior was reviewed on March 5, 2021. This review revealed that on May 12, 2020 at 12:45 p.m., Individual #1 reported that he had tied strings around his neck in order to harm himself. A nursing assessment revealed that this individual stated he wanted to go to the hospital, and a faint redness was noted to the anterior neck.

B. The investigation packet indicated that this individual has two staff with him in his living area within 3-15 feet. Prior to the event, Individual #1 was in his bedroom for approximately 45 minutes for private time. During this time, the two assigned staff were positioned to prevent this individual from elopement. The investigation did not evaluate the reason staff did not have visual contact with Individual #1 for 45 minutes while in his bedroom.

C. At 12:30 p.m., this individual requested to talk to members of his interdisciplinary team (IDT). Individual #1 met with IDT members and related that he attempted to harm himself. The investigation indicated that two shoestrings (issued by the facility) were found tightly tied to the grate over the ceiling light fixture. Inspection of this individual's shoes revealed that they had their shoestrings in them. The investigation did not evaluate how Individual #1 obtained the extra shoestrings.

D. Further review of the investigation packet revealed Individual #1 stated that he tied the "strings" on the grate [over the ceiling light] by standing on a "mat." According to the investigation, blocking pads located in this individual's area, could possibly have given him enough height if he stood on them to reach the grate and tie the shoelaces. The investigation did not evaluate the reason blocking pads were stored in the bedroom area when staff were positioned outside of the bedroom. The investigation determined that staff were not negligent for this occurrence.

E. The quality assurance/risk management director (QA/RMD) was interviewed on March 9, 2021. The QA/RMD confirmed the investigation was not thoroughly investigated to ensure Individual #1's safety.



Plan of Correction:

1. Conduct an Investigation Peer Review on individual #1 packet with Certified Investigators and the Administrative Review Team to identify areas lacking evaluation, evidence, details, and reconciliation as well as any additional corrective actions and preventative measures

Quality Assurance/Risk Management Director (QARMD) 04/08/2021

2. Train the Certified Investigators on the requirement to identify all types of evidence, seek additional details, when needed, and how the ability to conduct a thorough, quality investigation directly relates to the responsibilities the Administrative Review Team must uphold.

QARMD 04/08/2021

3. Monitor the status of completion of the training for the certified investigators.

QARMD 04/08/2021 and ongoing

4. Provide the completed training to the Facility Director (FD) and Division Directors (DD) at the monthly Plan of Correction (POC) meeting.

QARMD 04/09/2021, 5/14/2021, 6/11/2021

5. Train the Administrative Review Team on the requirement to request additional evidence and/or additional details and information from a Certified Investigator, in order to make an accurate final determination as well as corrective actions that are relatable for investigations and mitigate risk of similar incidents occurring in the future.

QARMD 04/08/2021

6. Monitor the status of completion of the training for the Administrative Review Team.

QARMD 04/01/2021 and ongoing

7. Provide the completed training to the FD and DD at the monthly POC meeting.

QARMD 04/09/2021, 5/14/2021, 6/11/2021

8. Conduct an Investigation Peer Review on a selection of two investigations of critical incidents for individual #1 since 5/12/20 to ensure the Administrative Review Team identified any areas lacking evaluation, evidence, details, and reconciliation as well as any additional corrective actions and preventative measures.

QARMD 05/07/2021

9. Provide a report of the results of Investigation Peer Reviews to the FD and DD at the monthly POC meeting.

QARMD 05/14/2021, 06/11/2021

10. Revise the "Five-day Report to Facility Director and Division Directors" form to include probe questions related to the reasons an incident/investigation occurred; to identify the need to obtain additional details via clarifying interviews; as well as a review of the relevant evidence identified to ensure a thorough investigation is being conducted.

QARMD 04/08/2021

11. Provide a report of the Revised "Five-day Report to Facility Director and Division Directors" form to the FD and DD at the monthly POC meeting

QARMD 04/09/2021

12. Implement the use of the revised "Five-day Report to Facility Director and Division Directors" form at the 5 day report out meetings to ensure a thorough investigation is being conducted for all investigations. Identify any areas that lack evaluation, evidence, or details, and identify and evidence that needs reconciled. Request additional evidence, details, interviews as warranted.

DD and QARMD 04/09/2021

13. Conduct ongoing training for Certified Investigators and the Administrative Review Team using the findings of the "Five-day Report to the Facility Director and Division Directors" form to assist with improving the quality of investigations and to mitigate the risk to prevent future incidents.

QARMD 04/09/2021 and ongoing

14. Provide an update of the training provided to Certified Investigators based on the findings of the "Five-day Report to the Facility Director and Division Directors" form to the FD and DD at the monthly POC meeting.

QARMD 04/09/2021, 05/14/2021, 06/11/2021

15. Conduct Investigation Peer Review on one investigation for critical incidents each month to assess the quality of investigations and identify areas of needed improvement while monitoring investigations and how risk mitigation is being done to prevent future incidents.

QARMD 05/14/2021 and ongoing

16. Provide a report of the results of the Investigation Peer Reviews to the FD and DD at the monthly POC meeting

QARMD 05/14/2021, 06/11/2021

17. Conduct ongoing training for Certified Investigators and the Administrative Review Team using the evaluation of the findings of the CI Peer Reviews conducted.

QARMD 05/07/2021 and ongoing

18. Provide an update of the training provided to Certified Investigators based on Peer Review findings to the FD and DD at the monthly POC meeting.

QARMD 04/09/2021, 05/14/2021, 06/11/2021



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 facility investigation report review, incident report review and staff interview, it was determined that facility staff failed to provide needed interventions and services in sufficient number and frequency to implement the Individual Support Plan for three individuals residing in the facility (Individuals #2, #3 and #4).Findings included:
A. Individual #2

1. A review of a certified investigation, incident report and repositioning records revealed that on October 17, 2020, Individual #2 was noted to have an open area on the right buttocks measuring 1 cm x 1 cm. The physician deemed the open area as pressure related on October 17, 2020. Individual #2 is at moderate risk for skin breakdown and has a history of open areas to the buttocks. Review of a Support Action plan revealed alternate seating supports provided to relieve pressure during the hours of 2:00 p.m. and 4:45 p.m. A review of the repositioning records revealed that #2 was not provided alternate seating from October 11, 2020 through October 17, 2020.

2. The facility determined neglect as a result of Individuals' support action plan not being followed.

B. Individual #3

1. A review of a facility investigation, dated February 19, 2021, revealed that Individual #3 acquired open areas and excoriation on the left buttock measuring a .75 cm and right buttock measuring .75 cm circular area and .1 cm deep. Individual #3 is a moderated risk for skin breakdown and has fragile skin. The physician examined the area on February 3, 2021 and stated that "scooching" in his wheelchair caused sheering in the area due to very fragile skin may have caused the open areas. Further documentation revealed that Individual #3 has a Support Action plan to be transferred into bed between 1:00 p.m. and 3:00 p.m. for alternate seating. Staff from the Horizon building stated in a witness statement that Individual #3 was not provided alternate seating on February 3, 2021 due to anticipating transport from the step-down unit in Horizon to the Keystone building. Staff interviews from Horizon stated that no open areas were noted. Individual #3 arrived at Keystone at 1:40 pm. Documentation of the repositioning record revealed that the individual was in his wheelchair from 1:00 p.m. to 3:00 p.m. on February 3, 2021. At 2:40 p.m., Keystone staff provided personal care and found excoriations and open areas on buttocks.

2. The facility determined neglect was confirmed as a result of Individual #3's supports not being provided on a consistent basis.

C. Individual #4

1. A review of a certified investigation, dated July 22, 2020, revealed that on July 9, 2020, Individual #4 was noted to have a 4 cm x 2 cm denuded area on the left buttocks and a 1 cm x 1 cm denuded area on the right buttocks. The physician deemed these areas as pressure related. The skin in this area is very fragile.

2. Individual #4 is totally dependent on staff for all activities of daily living. He utilizes a tilt-n-space wheelchair and a pressure relieving gel seat cushion. Individual #4 has a lengthy history of fragile skin to the buttock area. An observation by the physical therapist during the evaluation, dated July 10, 2020, revealed that Individual #4 was seated in his wheelchair with the Ergo mechanical lift sling under him. It was further revealed in the witness statement that "if the sling is left under him while seated in the wheelchair, it decreases the effectiveness of the pressure reducing seat cushion and can also bunch up under him and leave marks."

3. A review of the facility Five-Day/Weekly report revealed that the cause of the skin breakdown was possibly sheering during transfers from contact with the sling. The allegation of neglect was confirmed by the facility for not following the plan of care.

D. Interview with the Facility Director (FD) on March 15, 2021 at 11:00 a.m. confirmed the above-mentioned findings.



Plan of Correction:

01 Provide training for staff assigned to individual #2, 3 & 4 that individual 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. Documentation of this training is the Residential Services Aide (RSA) signature on the related Staff Instruction Records (SIR).

Residential Services Aide Supervisor/Residential Services Aide Night Supervisor (RSAS/RSANS) 04/09/2021

02 Residential Services Supervisor/Qualified Intellectual Disabilities Professional (RSS/QIDP) will update Repositioning and Alternate Seating plans for individual #2, 3 & 4.

RSS/QIDP 04/02/2021

03 Copies of updated Repositioning and Alternate Seating plans for individual #2, 3 and 4 are reviewed by the Residential Services Unit Manager (RSUM) to ensure knowledge of proper supports, needed interventions and active treatment. The RSUM signature and date on copies of the updated plans signifies review of content. Issues identified are addressed immediately.

RSUM 04/07/2021

04 Train staff who work with individual #2, 3 & 4 on updated Repositioning and Alternate Seating plans to ensure knowledge of proper supports, needed interventions and active treatment.

RSS/QIDP 04/07/2021 & ongoing

05 RSUM provides the completed and signed copies of the updated Repositioning and Alternate Seating plans and SIR to the Director of Residential Unit Managers (DRUM) for review prior to the Plan of Correction (POC) meeting.

RSUM 04/07/2021 & ongoing

06 DRUM reviews the completed and signed copy of the updated Repositioning and Alternate Seating plans and SIR to ensure accuracy, timely completion and sufficient number of staff trained. Issues identified are addressed immediately.

DRUM 04/09/2021 & ongoing

07 DRUM provides a report of the review of documentation to the Facility Director (FD) and Division Directors (DD) at the monthly POC meeting.

DRUM 04/09/2021, 05/14/2021, 06/11/2021

08 Initiate an audit for individual #2, 3 & 4 to ensure continuous active treatment with specific focus on skin integrity needs. Complete 3 observations per week for individual #2, 3 & 4 for 4 weeks. Any issues identified are corrected immediately.

RSAS/RSANS 04/30/2021

09 Completed audits and corrective actions are provided to the RSUM for review of content and thoroughness. RSUM signature and date on a copy of each observation verifies the review and thoroughness of content.

RSUM 04/30/2021

10 RSUM reviews the content and thoroughness of the completed audits to ensure timely completion and any issues identified were corrected and provides the completed audits to the DRUM for review.

RSUM 05/07/2021

11 DRUM provides a report of the review of audits to the FD and DD at the monthly POC meeting.

DRUM 05/14/2021, 06/11/2021

12 Provide training for all RSA staff that ALL individuals 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. Documentation of this training is the RSA staff signature on the related SIR.

RSAS/RSANS 05/07/2021

13 RSS/QIDP will identify all others who require a Support Action for alternate seating and provide a list to RSUM and DRUM.

RSS/QIDP 04/02/2021

14 Chief OT will identify all others who require a Bed/Cart/Wheelchair reposition record and provide a list to DRUM.

Chief OT 04/02/2021

15 DRUM creates a list of all others who require skin integrity supports.

DRUM 04/07/2021

16 OT, RSAS/RSANS, RSS/QIDP and RSUM staff conducts random observations to ensure appropriate needed interventions and active treatment are completed with focus to skin integrity concerns. Complete 1 audit per living area per week per building for one month. Any issues identified are addressed and corrected immediately.

OT, RSAS/RSANS, RSS/QIDP and RSUM 05/07/2021

17 Completed audits and corrective actions are provided to the RSUM for review of content and thoroughness. RSUM signature and date on a copy of each observation verifies the review and thoroughness of content.

RSUM 05/07/2021

18 RSUM/OT sends completed audits to the DRUM for additional review.

RSUM 05/07/2021

19 Completed audits are reviewed by the DRUM to ensure accurate and timely completion. Any issues identified are immediately addressed. The DRUM signature and date on each observation signifies the review of content and corrective actions.

DRUM 05/13/2021

20 DRUM presents a report of the completed audits to the FD and DD at the monthly POC meetings, noting any issues identified and corrective actions taken.

DRUM 05/14/2021, 06/11/2021

21 Create a binder for the Step Down Unit to maintain skin integrity documents which will include Repositioning Record and/or Alternate Seating SA.

RSW 04/09/2021 and ongoing

22 RSUM train staff in Step Down Unit on the purpose and location of the binder in order for staff to implement individual's Repositioning and Alternate Seating plans to ensure interventions, services and continuous active treatment with focus to skin integrity concerns.

RSUM 04/09/2021 and ongoing

23 RSUM will audit the binder weekly & following each new admission to the Step Down Unit.

RSUM 04/09/2021 and ongoing

24 RSUM reports out weekly to DRUM of the content of the binder.

RSUM 04/09/2021 and ongoing

25 DRUM provides a report of the review of binder audit to the FD and DD at the monthly POC meeting.

DRUM 04/09/2021, 05/14/2021, 06/11/2021



483.470(l)(1) STANDARD
INFECTION CONTROL

Name - Component - 00
There must be an active program for the prevention, control, and investigation of infection and communicable diseases.



Observations:

Based on observation, review of facility documentation and staff interview, the facility failed to ensure that an active program for the prevention and control of a communicable disease was maintained. This practice is specific to the implementation of the facility re-opening plan practices specific to COVID-19.

Findings included:

A. A walkthrough of Laurel Hall was completed on March 3, 2021 between 2:30 p.m. and 3:15 p.m. Interview with the Facility Director (FD) prior to the walkthrough revealed that Laurel Hall was classified as a Yellow Zone at that time. According to facility protocol, when a building has been designated a Yellow Zone, staff should be donning full PPE (gown, N95 Respirator, Goggles or disposable full-face shield, and clean non-sterile gloves).

Direct observations during the walkthrough revealed that several staff were not donning PPE in accordance with the Yellow Zone Protocol. Observations also revealed that seven staff members were not practicing social distancing as required. Examples included the following:

- Seven staff members were in the facility dining area and holding a change-of-shift meeting. All seven staff were sitting at the same table and did not social distance from one another. Also, the only PPE that was being used was a facemask. No face shield/goggles, gown, or gloves were noted.

- Observations in Laurel Hall West 1 revealed that one staff was walking around wearing a cloth mask. When the surveyors entered the day room, the staff obtained an N95 mask, gown, face shield, and gloves and then placed them on. One staff came out of the bathroom area wearing a cloth mask; however, an N95 mask or a face shield or eye goggles were not being donned. When the staff person noticed the surveyors, they obtained a face shield and placed it on.

- Observations in Laurel Hall West 2 revealed that two staff were wearing a gown without any mask or a face shield or eye goggles. When the surveyors walked into the area, the two staff put their cloth masks on and obtained face shields and placed them on.

- Observations in Laurel Hall East 2 revealed that two staff were sitting with an individual in the living area wearing a cloth mask and a gown. No N95 masks or face shields or eye goggles were being worn. During the time the surveyors were in the living area, the two staff never obtained or donned an N95 mask, face shield or eye goggles.

- Observations in a hallway office of Laurel Hall revealed that the two staff who were sitting in the office were not wearing any type of PPE.

- It should be noted that observations in Laurel Hall East 1 revealed that all the staff present had adhered to the Yellow Zone Protocol regarding PPE usage. Also, observations in Laurel Hall Nursing Office revealed that all the nurses present had adhered to the Yellow Zone Protocol regarding PPE usage.

B. Interview with the Quality Assurance Risk Management Director (QA/RMD) on March 8, 2021 at 1:00 p.m. confirmed the above-mentioned findings.



Plan of Correction:

01 Train staff who conduct screenings on proper personal protective equipment (PPE) usage for all zones.

Infection Control Nurse 04/09/2021 and ongoing

02 Train staff who conduct screenings to ensure anyone entering the facility has proper PPE and any issues identified are addressed immediately through the Lead Screener. The Lead Screener records identified issues and corrective actions on the COVID-19 Supervisor Checklist in the screening binder.

Infection Control Nurse 03/26/2021 and ongoing

03 COVID-19 Supervisor Checklist is reviewed once weekly by the Safety Manager to ensure any identified issues were addressed.

Safety Manager 04/02/2021 and ongoing

04 Safety Manager will report out at the Plan of Correction (POC) meeting.

Safety Manager 04/09/2021, 05/14/2021, 06/11/2021

05 Train all Laurel House staff on current PPE requirements for each zone (Green, Yellow, Red)

Infection Control Nurse 04/09/2021 and ongoing

06 Post COVID-19 exposure status at the entrances of Laurel House to inform anyone entering the building of the color zone they are entering and the PPE required for that zone before entering the building

Residential Services Unit Manager (RSUM) 03/26/2021

07 RSUM or designee will report out on the morning health meeting the color zone of their building.

RSUM or designee 03/26/2021

08 Conduct random weekly PPE audits in Laurel House on all shifts to include residential and office areas. Completed audits sent to Facility Director (FD) or designee for review.

RSUM, Residential Services Aide Supervisor (RSAS), Residential Services Aide Night Supervisor (RSANS), Registered Nurse Supervisor (RNS), Safety Manager, Infection Control Nurse 04/09/2021 and ongoing

09 Train all staff on PPE requirements for each zone (Green, Yellow, Red)

Infection Control Nurse 04/23/2021 and ongoing

10 Conduct random weekly PPE audits in all residential buildings on all shifts to include residential and office areas. Completed audits sent to FD or designee for review.

RSUM, RSAS/RSANS, RNS, Safety Manager, Infection Control Nurse 04/23/2021

11 Train all Laurel House staff on current guidance for social distancing.

RSUM 03/30/2021

12 Laurel House RSAS/RSANS to observe daily cross-shift meetings on every shift to ensure current guidance on social distancing is being adhered to. Any issues with proximity are addressed immediately.

RSAS/RSANS 03/30/2021 and ongoing

13 Laurel House RSAS/RSANS email daily cross-shift observations to the RSUM for review once per week.

RSAS/RSANS 04/02/2021 and ongoing

14 Train all staff on current guidance for social distancing.

DPS 04/07/2021

15 RSAS/RSANS staff in each residential building observe daily cross-shift meetings on every shift to ensure current guidance on social distancing is being adhered to. Any issues with proximity are addressed immediately.

RSAS/RSANS 04/07/2021 and ongoing

16 RSAS/RSANS staff email daily cross-shift observations to the RSUM for review once per week.

RSAS/RSANS 04/02/2021 and ongoing

17 RSUM reviews observations and reports out on observations at the POC meeting.

RSUM 04/09/2021, 05/14/2021, 06/11/2021