QA Investigation Results

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


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Initial Comments:

A monitoring visit was conducted September 13-14, 2022, 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 consisted of two individuals. Four deficiencies were cited.






Plan of Correction:




483.420(d)(2) STANDARD
STAFF TREATMENT OF CLIENTS

Name - Component - 00
The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures.

Observations:

Based on documentation review and staff interview, it was determined that the facility failed to immediately report an incident of peer-to-peer abuse to administration. This was noted for the only investigation conducted since the recertification survey completed on May 9, 2022. The findings included:
A) Facility incident reports and investigations from May 9, 2022 through present were reviewed on September 13-14, 2022. This review revealed an investigation into peer-to-peer abuse which was completed on July 21, 2022. The investigation indicated that the incident occurred on July 9, 2022 and was discovered on July 11, 2022.
B) The acting program director (APD) was interviewed on September 13, 2022, at 5:00 PM. The APD confirmed that the peer-to-peer abuse was not immediately reported to facility administration.








Plan of Correction:

Facility staff will be retrained in Abuse, Neglect and Mistreatment policies and procedures for identifying incidents and reporting incidents immediately to administration. As part of the training, staff will also be retrained in CSG's policies and procedures for Who to Call for Help which outlines not only when staff are to call 911 and when to call Station MD, but also when staff are to call on-call when an incident occurs outside of regular business hours. The document identifies staff are to call on-call in situations involving suspected abuse, neglect and mistreatment, as well as behavioral issues involving aggression. The above identified training will be conducted by the Program Director with all existing employees by 10/21/2022. New employees will be trained in the identified training during orientation. Documentation of training will be maintained in the google folder specified for this inspection and the Director of IDD Services will monitor the completion of the training. Monitoring to ensure immediate reporting of all allegations of abuse/neglect/mistreatment will be completed through the review of shift notes, the home's chat room and on-call notes by a nurse, QIDP and/or supervisor/manager on a daily basis. If an allegation of abuse/neglect/mistreatment is found to have not been reported immediately, corrective action will be taken with the employee by the employee's designated supervisor, which may be the Program Supervisor, Program Manager, Program Director or Health Services Coordinator.



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 documentation review and staff interview, it was determined that the facility failed to thoroughly investigate an allegation of abuse, neglect, or mistreatment. This was noted in the only investigation conducted since the recertification survey completed on May 9, 2022. The findings included:
A) Facility incident reports and investigations from May 9, 2022 through present were reviewed on September 13-14, 2022. This review revealed an investigation into peer-to-peer abuse which was completed on July 21, 2022. The investigation indicated that the incident occurred on July 9, 2022 and was discovered on July 11, 2022. The report indicated that the incident was reported "within the required time". The investigation did not identify that the peer-to-peer abuse was not immediately reported to administration.
The report indicated that "staff documented that [Individual #1] was sitting in the living room in his broda chair when his housemate [Individual #2] was walking by assisted by staff, [Individual #2] slapped [Individual #1] with his hands, [Individual #1] covered his face..." The investigation did not indicate how the peer-to-peer abuse documentation was discovered and by whom.
The investigative report indicated that staff did not implement the safety plan for Individual #2. The determination of the administrative review confirmed "individual to individual abuse". However, there was no documentation that the administrative review evaluated the failure to provide needed service for Individual #2.
B) The acting program director (APD) was interviewed on September 13, 2022, at 5:00 PM. The APD confirmed that the investigation did not contain the above information.















Plan of Correction:

The Investigation Specialist will review and retrain investigators in determining how and by whom the incidents of abuse, neglect and mistreatment are discovered, as well as if incidents are not reported in a timely manner, why they were not immediately reported to administration. Investigators will be retrained in documenting this information in the investigative summary and findings. Investigators will be retrained in reporting additional findings of alleged failure to provide needed services to administration upon discovery. The Investigation Specialist will also review with the Administrative Review Team the need to document the completion of an evaluation to determine if there is any finding of failure to provide needed services for an individual. The Investigation Specialist will complete training with investigators and the review with the Administrative Review Team by 10/31/2022. Documentation of training and reviews will be maintained in the google folder identified for this inspection and the Director of IDD Services will monitor the completion of the training and review. Monitoring to ensure thoroughness will be completed through the initial 5 day review of the investigation by administration, in addition to the review of the investigation by CSG's Administrative Review Team upon reported completion of the investigation by the investigator. The Administrative Review Team may request additional information for thoroughness of the investigator before completing a final administrative review. Investigations will be also be monitored for thoroughness through the Certified Investigators Peer Review process occurring on a Quarterly basis in the months of December, March, June and September. The CI Peer Review Team forwards the results of the investigation reviews to the investigator's supervisor for review with the investigator. If an investigation is not thorough, the investigator's supervisor will provide feedback and develop a plan for improvement.



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 prevent further harm while an investigation was in progress. This was noted in the only investigation conducted since the recertification survey completed on May 9, 2022. The findings included:
A) Facility incident reports and investigations from May 9, 2022 through present were reviewed on September 13-14, 2022. This review revealed an incident of peer-to-peer abuse occurred on July 9, 2022 and was discovered on July 11, 2022. The investigation was assigned to an investigator on July 14, 2022, and the report was completed on July 21, 2022. The investigation indicated that "no staff were suspended for the incident as the investigation did not show until later that staff did not follow the safety plan of one of the men involved in the incident."
B) The acting program director (APD) was interviewed on September 13, 2022, at 5:00 PM. The APD confirmed that the staff, who were present for the peer-to-peer abuse, were not removed during the investigation process to prevent further harm.

















Plan of Correction:

Target staff identified for incidents involving allegations of abuse, neglect or mistreatment will be immediately removed from care for individuals upon the incident occurring, or the discovery of the incident. Monitoring to ensure target staff are removed immediately to prevent further potential abuse, neglect
or mistreatment will be completed by the Program Director through the review of the reported incident and discussion with the employee's designated supervisor, manager or on-call supervisor. If discovered a target employee had not been immediately removed from client contact, the target will be immediately removed. In addition, the initial findings of an investigation will be reviewed by the Program Director within five days of the start of an investigation to evaluate and determine if the health and safety of an individual(s) is addressed, appropriately. If the initial findings identify additional allegations, the Program Director will take immediate action to ensure the health and safety of the individual. This may include, but is not limited to, immediate corrective action, training or suspension of an employee. Documentation of the administration's review of the initial findings and actions taken to ensure health and safety will be documented in the Administrative Review for the investigation. The Administrative Review Team will be responsible for reviewing the investigation to ensure all required information is included in the investigation, including the preliminary findings of the investigation completed within the first five days of the investigation.



483.420(d)(4) STANDARD
STAFF TREATMENT OF CLIENTS

Name - Component - 00
The results of all investigations must be reported to the administrator or designated representative or to other officials in accordance with State law within five working days of the incident.

Observations:

Based on documentation review and staff interview, it was determined that the facility failed to ensure preliminary findings to an investigation were reported to administration within five (5) working days of the incident. This was noted for the only investigation conducted since the recertification survey completed on May 9, 2022. The findings included:
A) Facility incident reports and investigations from May 9, 2022 through present were reviewed on September 13-14, 2022. This review revealed an incident of peer-to-peer abuse occurred on July 9, 2022 and was discovered on July 11, 2022. The investigation was assigned to an investigator on July 14, 2022, and the investigative report was completed on July 21, 2022. An administrative review was not completed until July 28, 2022.
B) The acting program director (APD) was interviewed on September 13, 2022, at 5:00 PM. The APD confirmed that the investigation findings were not reported to administration within five working days of the incident.















Plan of Correction:

The Director of IDD Services will review with the Program Directors and Certified Investigators the requirement to review preliminary findings of an investigation within five days of the incident occurring or the discovery of the incident and this review will be documented and completed by 10/31/2022. The review will include the need to evaluate the appropriateness of steps taken to ensure health and safety of individuals, which may include but is not limited to training, corrective action or suspension of employees in investigations involving alleged abuse, neglect or mistreatment of individuals. The review will also include the need for Program Directors to evaluate the accurate classification of incidents. Program Directors will ensure the preliminary findings have been recorded and filed with the investigation. The Program Directors will schedule a meeting with the investigator to be held no more than five days from the incident occurring or the discovery of the incident for the preliminary review of the initial findings. The Director of IDD Services will monitor on a weekly basis for 3 months to ensure preliminary findings are reported to administration within 5 days of the incident occurring or the discovery of the incident and documented and filed with the investigation.