Initial Comments:
An initial validation survey visit was conducted on February 27 and 28, 2024. The purpose of this visit was to determine compliance with the requirements of 42 CFR, Part 441.184, Subpart D Emergency Preparedness regulations for Medicare and Medicaid participating providers and suppliers.
The ABH-Pennsylvania Children's Services Inc. Greenway Left facility is in compliance with the requirements of 42 CFR, Part 441.184, Subpart D Emergency Preparedness regulations for Medicare and Medicaid participating providers and suppliers.
Plan of Correction:
Initial Comments:
An initial validation survey visit was conducted on February 27 and 28, 2024. The purpose of this visit was to determine compliance with the requirements of 42 CFR, Part 483, Subpart G regulations for Psychiatric Residential Treatment Facilities for children under age 21. The census at the time of the visit was six, and the sample consisted of four residents.
Plan of Correction:
483.374(b) ELEMENT
FACILITY REPORTING
Name - Component - 00
Reporting of serious occurrences.
The facility must report each serious occurrence to both the State Medicaid agency and, unless prohibited by State law, the State designated Protection and Advocacy system.
Serious occurrences that must be reported include;
- a resident's death;
- a serious injury to a resident as defined in section §483.352 of this part; and
- a resident's suicide attempt.
(1) Staff must report any serious occurrence involving a resident to both the State Medicaid agency and the State designated Protection and Advocacy system by no later than close of business the next business day after a serious occurrence. The report must include
- the name of the resident involved in the serious occurrence,
- a description of the occurrence and,
- the name, street address, and telephone number of the facility.
Observations:
Based on review of a facility incident report and interview with the administrative staff, the facility failed to report a serious occurrence to both the State Medicaid agency and the state designated protection and advocacy system which resulted in serious injury requiring surgery for one of one sample Individual who inserted a foreign object into his nose. This practice is specific to Resident #3.
Findings include:
1. A review of the facility's incident reports, and resident records was completed on 02/28/2024 between 8:30 AM and 9:00 AM. This review revealed the following
information which was documented on the facility incident report as outlined.
- Facility incident report dated 01/23/2024:
"On 01/22/2024, staff reported to the second shift nurse, that there was a foul odor coming from Resident #3 ' s nose." According to this report the nurse added Resident #3 to medical clinic list for the following day.
Resident #3 was seen by the doctor at the facility medical clinic on 01/23/2024 at 8:45 AM. and he was noted to be uncooperative during this evaluation. The facility doctor instructed that Resident #3 should be assessed at the emergency department at the Children's Hospital of Philadelphia,
King of Prussia campus (CHOP KOP). Resident #3 was seen at CHOP KOP emergency room at 12:02 PM on this date. According to the incident report, Resident #3 was examined and the ER doctor did not see a foreign object in Resident #3's nasal passage and scheduled an ENT ( ear, nose and throat) appointment for 01/24/2024.
On a subsequent appointment with CHOP ENT services on 01/24/2024, visual examination of the nasal cavity was completed under sedation, and a suspicious right nasal foreign body was found. Resident #3 was scheduled for surgery to remove the foreign body.
On 01/25/2025, surgery was completed at this same location in order to remove the foreign body, a penny, from resident#3's nose.
Further review of the incident report documentation dated 1/23/2024, and subsequent record review noted that there was no indication that the faiclity had reported this serious injury to either the State Medicaid agency and Pennsylvania protection and advocacy system (Disabilities Rights Network).
Interview with the Quality Improvement Coordinator on 02/28/2024 at approximately 9:00 AM, confirmed that facility did not report this serious occurrence to either the State Medicaid agency or the state designated protection and advocacy system.
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Plan of Correction:1. N/A – Notification of serious injury was not reported in the State reporting database The Home and Community Services Information System (HCSIS) and not reported to Disability Rights Network.
2. Review of all additional incidents for month of October 2023 - February 2024 was completed on 3.1.24 and did not identify any additional incidents meeting reporting requirements.
3. The Program Director (or designee) will monitor incident reports by reviewing reports in the Devereux electronic incident reporting system and ensure incidents related to serious occurrences are entered into The Home and Community Services Information System (HCSIS) database within 24 hours. Program Director will include HCSIS # in the electronic incident report to confirm reporting has occurred. Staff will sign off in acknowledgement of the training and the acknowledgement will be filed in the employee's personnel file. Quality Department will ensure reportable incidents are submitted to the Bureau of Program Integrity (BPI), and the Disability Rights Network (DRN).
4. Quality Department will review all incident reports on a daily basis during regular business hours to ensure compliance with program entries into the State Database (HCSIS) and will report any deficiencies to the Director of Quality Improvement. Quality Department will also ensure reports meeting reportable are submitted to the Bureau of Program Integrity (BPI) and the Disability Rights Network (DRN). Fax confirmation sheets will be maintained as evidence to support these notifications.
5. Oversight by Director of Quality Improvement. For any deficiencies identified during Quality Department's review of incidents related to serious occurrences and notifications to the Bureau of Program Integrity (BPI) Disability Rights Network (DRN), Director of Quality Department will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
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