QA Investigation Results

Pennsylvania Department of Health
COMMUNITY SERVICES - HANS HERR
Health Inspection Results
COMMUNITY SERVICES - HANS HERR
Health Inspection Results For:


There are  26 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 May 12-14, 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 three and the sample original consisted of two individuals. Seven deficiencies were identified.




Plan of Correction:




483.420(a)(7) STANDARD
PROTECTION OF CLIENTS RIGHTS

Name - Component - 00
The facility must ensure the rights of all clients. Therefore, the facility must ensure privacy during treatment and care of personal needs.



Observations:

Based on observation and staff interview, it was determined that the facility failed to ensure privacy during treatment and personal care. This was noted for one of the two individuals who were observed during medication administration (Individual #2). The findings included:
A) On May 12, 2021, medication administration was observed between 7:17 AM and 7:55 AM. This observation revealed the staff administering medications (SAM) prepared Individual #2's medication at 7:45 AM. The SAM then walked to the bathroom in the facility's back hallway, knocked and opened the door. Individual #2 was seated on the toilet in the process of a bowel movement. The SAM fed this individual oral medications while he was seated on the toilet.
B) The SAM was interviewed after the administration of medications to Individual #2. The surveyor explained that individuals have a right to privacy during personal care and medication administration. The SAM stated that the training did not cover individuals' privacy during personal care and medication administration of oral medications.




Plan of Correction:

QIDP will train/retrain all staff members on Policies, Procedures and Guidelines which includes the individual's right to have privacy in the bathroom. QIDP will reeducate all staff members on the importance of not administering medications while an individual is utilizing the restroom. Training with staff members will be completed by 6/11/2021. The Program Director will verify training of staff members and document on staff training records.
The nurse will complete and document random unannounced checks to verify compliance. The nurse will complete and document observation of proper administration practices each shift (7am-3pm, 3pm-11pm, and 11pm-7am) once per week. After four consecutive weeks of proper administration practices with no errors, one observation will be completed each shift one time per month. After 3 consecutive months of proper administration, the observation will be complete on a random ongoing basis. All observations will be documented by the nurse and reviewed by the program director each quarter to verify completion.



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 observations, record review, and staff interview, it was determined that the facility failed to implement each individual's program plan for poisonous materials. This was noted for all three individuals in the facility (Individuals #1, #2, and #3). The findings included:
A) On May 12, 2021, at 10:25 AM, a physical plant inspection was conducted with the qualified intellectual disabilities professional (QIDP). Observations revealed that a bottle of "Fantastic" multi-purpose cleanser spray was in an unlocked cabinet under the bathroom sink. Individual #2 was observed seated on the toilet next to this sink at 7:55 AM. Further observations revealed automatic dishwasher detergent in an unlocked cabinet under the kitchen sink.
B) The QIDP was interviewed at the time of the discovery and confirmed that poisons are to be locked in the facility for the benefit of all three individuals.
C) The records of Individuals #1 and #2 were reviewed. These reviews revealed written informed consents and human rights committee approval to have all poisonous materials kept locked in the facility.




Plan of Correction:

All poisonous materials were moved and stored in a locked cabinet on May 12, 2021.
QIDP will re-educated all staff members on the importance of monitoring all poisonous materials in the home to ensure when they are not in immediate use, they are to be stored and locked at all times.
QIDP will reeducate all staff members on the Policy and Procedure for OSHA exposure Control Plan and Hazard Communication Plan. Training with staff members will be completed by 6/11/2021. The Program Director will verify training of staff members and document on staff training records.
The QIDP will complete and document random unannounced checks to verify compliance. The QIDP will complete and document observation of proper storage of poisons each shift (7am-3pm, 3pm-11pm, and 11pm-7am) once per week. After four consecutive weeks of proper administration practices with no errors, one observation will be completed each shift one time per month. After 3 consecutive months of proper administration, the observation will be complete on a random ongoing basis. All observations will be documented by the QIDP and reviewed by the program director each quarter to verify completion.



483.470(d)(3) STANDARD
CLIENT BATHROOMS

Name - Component - 00
The facility must, in areas of the facility where clients who have not been trained to regulate water temperature are exposed to hot water, ensure that the temperature of the water does not exceed 110 degrees Fahrenheit.



Observations:

Based on documentation review and staff interview, it was determined the facility failed to maintain hot water temperature to 110 degrees Fahrenheit for two individuals in the facility (Individuals #1, and #2). The findings included:
Individual #2 was admitted to the facility on November 19, 2020. Individual #3 was admitted to the facility on May 11, 2021.
A) Emergency evacuation drill reports were reviewed on May 12, 2021. This review revealed hot water temperatures were documented with each monthly report. The temperatures above 110 degrees Fahrenheit were as follows:
December 31, 2020 - 114 degrees Fahrenheit
January 26, 2021 - 116 degrees Fahrenheit
February 23, 2021 - 115 degrees Fahrenheit
B) On May 12, 2021, at 9:30 AM, the surveyor asked the qualified intellectual disabilities professional (QIDP) to check the water temperature in the bathroom located in the back hallway. The temperature registered below 110 degrees Fahrenheit. The QIDP was interviewed at 9:58 AM, and confirmed that the documented water temperatures in December, January and February exceeded the limits for those individuals who cannot consistently regulated water temperatures. The QIDP stated that Individuals #1, #2, and #3 cannot consistently regulate hot water temperature.














Plan of Correction:

The Safety and Fire Checklist form has been updated to show the acceptable water temperature range for an ICF home to be no higher than 110 degrees. The water temperature will be checked in each bathroom each month by the QIDP or designee and documented on the Safety and Fire Checklist. If the water temperature reads higher than 110 degree the following protocol will be followed:

Water testing should not occur after hot water has been used frequently, i.e. not after several showers or loads of laundry.
Staff should test the water as follows:

The hot water should run for at least 15-30 seconds
Using a glass or ceramic mug, staff should let the water flow into it
While the water is flowing into it, staff should insert the thermometer and measure the temperature

Staff will document the water temperature on the Safety and Fire Checklist Form. If the water temperature is lower than the required 110, no other action is necessary.
If the water temperature is over the required number, staff must report this to the QIDP or to an on-call staff immediately. Instructions will be provided to adjust the water tank thermostat immediately.
The supervisor (IDD programs only), QIDP or on-call staff will make arrangements for the temperature controls to be adjusted.
The water temperature must be retested after adjustments are made.
When water temperatures exceed the established safety standard, it is imperative that staff regulate water temperatures for all individuals in the home when using hot water.

This procedure will be followed on an ongoing basis. Training with staff members will be completed by 6/11/2021. The Program Director will verify training of staff members and document on staff training records.



483.470(g)(2) STANDARD
SPACE AND EQUIPMENT

Name - Component - 00
The facility must furnish, maintain in good repair, and teach clients to use and to make informed choices about the use of dentures, eyeglasses, hearing and other communications aids, braces, and other devices identified by the interdisciplinary team as needed by the client.




Observations:

Based on observation, record review and staff interview, it was determined that the facility failed to provide/utilize adaptive equipment to promote the individuals' independence and safety. This was noted for two newly admitted individuals (Individuals #2 and #3). The findings included:
Observations were conducted on May 12, 2021, between 7:00 AM and 11:30 AM.
A) Individual #2 was observed to eat his breakfast of eggs and toast with a built-up fork. Staff handed this individual a regular spoon to eat a fruit cup at the end of breakfast.
Review of Individual #2's record revealed an occupational therapist evaluation, dated January 14, 2020. This evaluation indicated that "foam put on utensils with all meals to ease manipulation of utensils."
The nurse was interviewed on May 13, 2021, at 2:25 PM. The nurse confirmed that Individual #2 should be provided with built up utensils at every meal.
B) Observations revealed that Individual #3 was supported with "contact guard" by staff when ambulating throughout the home. The surveyor noted that some areas of the home are narrow, and staff had to walk behind this individual while maintaining contact. Individual #3 was observed leaning forward while staff were positioned behind him in the narrow hallway.
On May 12, 2021, at 9:30 AM, the surveyor mentioned to the qualified intellectual disabilities professional (QIDP) that Individual #3 should be evaluated for the use of a gait belt. The QIDP stated that this individual has an order for one.
A review of the physician's orders, dated April 22, 2021, indicated "gait belt as needed for ambulation" of Individual #3. A gait belt was placed on this individual after the surveyor brought it to the QIDP's attention.








Plan of Correction:

The Program Director purchased additional foam grip tubing for utensils to ensure one is always available when needed. The foam will be placed on clean utensils each time individual #2 is using it. The new foam grips were delivered to the house for use on May 29, 2021.
QIDP will reeducate all staff members on the Occupational Therapist recommendations to help the individual in their feeding process. Training for staff members will be completed by 6/11/21
QIDP will complete and document random unannounced checks to verify compliance. The QIDP will complete and document observation of proper use of foam grips each shift (7am-3pm, 3pm-11pm, and 11pm-7am, when applicable) once per week. After four consecutive weeks of proper use with no non compliance, one observation will be completed each shift, each month for 3 months. After 3 consecutive months of use of foam grips, the observation will be complete on a random ongoing basis.

The Program Director purchased additional gait belts for the house to ensure a clean belt is available for use daily. The additional belts were delivered to the house May 27, 2021.
QIDP will educate staff members on the importance of using a gait belt for individual #3 in the home and review the fall care plan. The nurse will review proper use of gait belts and document training on a sign in sheet for training. Staff training records will be updated to show completion of training. Training with staff members will be completed by 6/11/2021. The Program Director will verify training of staff members and document on staff training records.

The nurse will complete and document random unannounced checks to verify compliance. The nurse will complete and document observation of proper use of gait belts each shift (7am-3pm, 3pm-11pm, and 11pm-7am, when applicable) once per week. After four consecutive weeks of proper use with no non compliance, one observation will be completed each shift one time per month. After 3 consecutive months of proper administration, the observation will be complete on a random ongoing basis.
The nurse will review all documentation on appointments to ensure all required assistive equipment is received and used as directed. The nurse will note in the electronic health record a review of appointments and recommendations are followed to ensure this does not occur for future needs.


483.470(i)(1) STANDARD
EVACUATION DRILLS

Name - Component - 00
The facility must hold evacuation drills at least quarterly for each shift of personnel.



Observations:

Based on documentation review and staff interview, it was determined that the facility failed to ensure evacuation drills were conducted during the third shift of personnel on a quarterly basis. This was noted for the two quarters reviewed. The findings included:
A) Evacuations drills from the last recertification survey (October 1, 2020) through present were reviewed on May 12, 2021. This review revealed no third shift evacuation drills were conducted during the last quarter of 2020, as well as the first quarter of 2021.
B) The qualified intellectual disabilities professional (QIDP) was interviewed on May 12, 2021, at 9:58 AM. The QIDP confirmed that there was no documentation that an evacuation drill was conducted on the third shift of personnel for both quarters mentioned.









Plan of Correction:


QIDP created and will utilize a tracking chart to ensure that each quarter, each shift (7a-3p, 3p-11p and 11p-7a) has a completed fire drill. QIDP will retrain all staff on proper completion of the fire safety checklist and tracking form to ensure a drill is completed on each shift for each quarter by 6/11/2021.

The Program Director will monitor all drills to ensure they are conducted and compare them to chart to ensure all three shifts had drills conducted in the calendar quarter. This review will be completed prior to the end of each quarter. If PD finds non compliance during monitoring, The PD will direct additional drills completed prior to the end of the quarter.



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 observations, documentation review, and staff interview, it was determined that the facility failed to ensure an active prevention and control program for COVID 19. This was noted for one staff member and the surveyor entering the facility. The findings included:
A) Observation on May 12, 2021, at 6:45 AM, revealed signs on the facility door to indicate that staff members will have their temperature checked and asked questions concerning the communicable disease. The sign also indicated that visitors would be screened upon entering the facility.
At 6:55 AM, the surveyor rang the doorbell at the front entrance to the facility. The staff member who opened the door did not have a face covering on but donned a mask after the surveyor presented identification and entered the facility.
B) Review of the facility's "Re-opening implementation plan" revealed that all visitors will enter and exit through the front door. In addition, physical distancing, universal masking, and hand hygiene are required for all visits.
Further review of the plan revealed a section entitled "Screening for all other persons entering the home". This section included, but not limited to, the following steps:
1. All persons entering the home will be screened at the front entrance of the home.
2. All persons entering the home will be asked screening questions by a designated staff person.
3. All persons will have their temperature taken at the front entrance of the home.
4. If the person passes all screening questions, they will immediately go and wash their hands before proceeding in the home. Hand sanitizing stations are also available in the home.
C) The qualified intellectual disabilities professional (QIDP) was interviewed on May 12, 2021, at 10:45 AM. The QIDP confirmed that the surveyor should have been screened at the front entrance with questions and a temperature check. In addition, the staff member was to wear a face covering while in the facility. The QIDP acknowledged that the facility's plan to prevent and control a communicable disease was not implemented.








Plan of Correction:

QIDP will re-train all staff on screening procedures for staff and visitors entering the house. Screening will include asking of the health questions, hand washing and temperature checks before entrance to the house is permitted. A chart for documenting temperatures will be kept at the entrance of the house.
Training will also include instructions on maintaining appropriate distance between others in the home unless providing personal care support. All staff will be reminded to wear facial covering at all times. Training with staff members will be completed by 6/11/2021. The Program Director will verify training of staff members and document on staff training records.
QIDP will complete random observations of staff and visitors entering the home to ensure staff members and visitors are being screened as required. The observations will be completed and documented each shift (7am-3pm, 3pm-11pm, and 11pm-7am, when applicable) once per week. After four consecutive weeks of proper texture and consistency with no non compliance, one observation will be completed each shift one time per month. After 3 consecutive months of proper administration, the observation will be completed on a random ongoing basis.
This process will continue until state guidelines are changed or updated. Observations will be documented by the QIDP and verified for completion by the Program Director each quarter.



483.480(a)(1) STANDARD
FOOD AND NUTRITION SERVICES

Name - Component - 00
Each client must receive a nourishing, well-balanced diet including modified and specially-prescribed diets.



Observations:

Based on observation, record review and staff interview, it was determined that the facility failed to provide a specially prescribed diet to a newly admitted individual (Individual #3). The findings included:
Individual #3 was admitted to the facility on May 11, 2021.
A) The breakfast meal was observed on May 12, 2021, at 8:45 AM. This observation revealed that Individual #3 was fed a pureed meal by staff. Approximately halfway through the meal, this individual yelled at the staff "one at a time". The surveyor asked the staff who was feeding Individual #3, what was being served from the small bowl, staff stated "baby crackers, he likes them".
B) Another staff member retrieved the "baby crackers" from the cupboard to show the surveyor. The surveyor turned to the qualified intellectual disabilities professional (QIDP) and asked what is the physician's order for Individual #3's diet. The QIDP stated pureed, but he ate the "baby crackers" at his previous facility.
C) A review of Individual #3's physician's orders, dated April 22, 2021, indicated this individual's diet was pureed consistency since October 15, 2019. There was no indication that "baby crackers" were permitted in the pureed diet order. The QIDP instructed the staff to cease feeding Individual #3 the "baby crackers".









Plan of Correction:

The puffed crackers were removed from the house on the day of the observation, May 14, 2021.

QIDP will re-train staff members on the importance of following all prescribed diets from the PCP. Staff members will be retrained on what constitutes a pureed diet to include consistency and texture permitted. Training will be completed by 6/11/21. The Program Director will verify training of staff members and document on staff training records.
The nurse will review all documentation on appointments to ensure all required diets are followed as directed. The nurse will note in the electronic health record a review of appointments and recommendations are followed to ensure this does not occur in the future.


The nurse contacted PCP for individual #3 on May 20, 2021 for a referral for additional swallow testing to be completed to ensure the proper recommended diet is followed. The swallow study was completed on 6/3/2021 and confirmed the findings of pureed diet order.

The nurse will complete and document random unannounced checks to verify compliance. The nurse will complete and document observation of proper texture and consistency of foods each shift (7am-3pm, 3pm-11pm, and 11pm-7am, when applicable) once per week. After four consecutive weeks of proper texture and consistency with no non compliance, one observation will be completed each shift one time per month. After 3 consecutive months of proper administration, the observation will be completed on a random ongoing basis.