QA Investigation Results

Pennsylvania Department of Health
ALLIED HEALTH CARE SERVICES INC - LYNETT VILLAGE
Health Inspection Results
ALLIED HEALTH CARE SERVICES INC - LYNETT VILLAGE
Health Inspection Results For:


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Initial Comments:


An onsite complaint investigation was conducted on Janaury 17, 18, and 24, 2024, to determine compliance with the requirements of the 42 CFR part 483, Subpart I, Requirements of Intermediate Care Facilities. Four deficiencies were identified as a result of the onsite investigation.












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 documentation review, record review, and staff interview, it was determined that the facility failed to thoroughly investigate an incident of potential sexual abuse for one individual. (Individual #1)

The findings included:

A. Individual #1

1. Staff interview with the Assistant Supervisor on January 18, 2024 and the Program Director on January 24, 2024, review of facility file note dated December 7, 2023, and review of daily ICF Behavior notes dated December 7, 2023 revealed that on December 7, 2023 at 8:00 AM during a behavioral episode Individual #1 made the following allegations regarding potential sexual abuse. She alleged that Target staff #1 and Target staff #2 "sexually assaulted me." She also alleged that another staff Target staff #3 "raped me." She alleged that she was "gang raped" by all target staff.

2. Interview with the Program Director further revealed that an incident report was not completed at the time nor was a formal investigation initiated and completed regarding the allegations.

B. Interview with the Assistant Vice President (AVP) on January 24, 2024 at 3:15 PM confirmed that the facility failed to thoroughly investigate one unusual incident for one individual.




























Plan of Correction:

W154 Staff Treatment of Clients
This deficient area involves failure by the facility to conduct an investigation for an alleged incident of sexual abuse. The facility was aware of the incident on 12/7/23 that occurred with Individual #1 who during a behavioral incident made allegations of sexual abuse, but due to the context of how the allegations were elicited, the facility erred in deciding to address it as a behavioral incident after discussions with staff, family and the individual's supports coordination.

All allegations of sexual abuse should be investigated with conclusions to confirm or not confirm whether the incident had validity to constitute whether abuse had occurred.

To address the deficient area, the facility will conduct an investigation of the 12/7/23 incident with interviews with "targets" #1, #2, and #3. The findings of the investigation will be documented and available for review.

To address all other individuals who may be adversely affected by the deficient practice, the facility Assistant Vice President will meet with the Interdisciplinary Team (QIDP, Program Specialists, Supervisors, Nursing, Staff Training Coordinator) to discuss to discuss the 12/7/23 incident, as an example, to emphasize that all allegations of sexual abuse need to be thoroughly investigated to determine whether the allegation is "confirmed" or "not confirmed". Documentation of the investigation should include:

- Background Information: This information should identify the individual's diagnosis, relevant medications, Behavioral Support Plan, environmental factors that may be relevant to the situation.
- The Incident: Provide details of what actually happened.
- Testimony: Interviews with staff.
- Physical and Documentation Evidence:
- Conclusions and Findings: "Confirmed"-"Not Confirmed"-"Inconclusive"
- Facility Action: Discipline and training of staff, Interdisciplinary Team review of individual's Program Plan. and modifications/implementations of new strategies to eliminate reoccurrence.

The facility will monitor progress for the plan of correction through documentation in the monthly Incident Management Meetings with documentation of all incidents. The Assistant Vice President, in conjunction with the Program director and Program Manager, will be ultimately responsible for successful plan of correction for W154, and elimination of future deficiencies related W154.





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 staff interview and documentation review, it was determined facility administration failed to provide for one individual's safety after an incident of potential sexual abuse was alleged by Individual #1 to staff and subsequently reported to administration. Administration failed to remove the identified targets of the allegations.

The findings included:

A. Individual #1

1. Interview with the Program Director on January 24, 2024 at 12:30 PM and review of a facility administrative file note revealed that three staff persons, alleged to have been involved in an incident of potential sexual abuse involving Individual #1 on December 7, 2023, at 8:00 a.m., were allowed to work with individuals in the facility after the incident of alleged abuse was reported to administration by the facility staff. Administration did not remove the identified targets after receiving the allegations of potential sexual abuse. Nor was a formal investigation completed into the incident. The targets of the allegations of abuse continued to work with Individual #1 and other individuals after the incident of potential sexual abuse had been reported.

B. Interview with the Assistant Vice President on January 24, 2024 at 3:30 PM., confirmed that facility administration failed to provide for one individual's safety after being informed of an allegation of potential sexual abuse.
















Plan of Correction:


W155 Staff Treatment of Clients
This deficient area focuses on the facility's failure to conduct an investigation for a behavioral incident that occurred on 12/7/23, where Individual #1 claimed she was sexually assaulted, raped and gang raped, then in W155 failed to remove the targets from the victim pending the outcome of the investigation. Failure to do so, undermined the safety, of the alleged victim.

To address the deficient area, the facility will implement the following corrective action and systematic changes:

- The (3) targets of the alleged incident were suspended pending outcome of the investigation.
- The facility Assistant Vice President commenced with a formal investigation.
- The facility Assistant Vice President contacted Area Agency on Aging, and a AAA investigator started their investigation on-site on 1/30/24. Local law enforcement was contacted through Area agency on Aging.

The facility will maintain the completed investigation on file that will include the Facility Conclusions and Findings & Facility Action. One clear action will be the obligation of the facility to conduct an investigation on "any" allegation despite what the allegation may appear on face value.

To address all others who could be adversely affected by the deficient practice, any and all investigations of alleged abuse, will result in separation of the alleged target(s) and the alleged victim.

The facility will monitor progress with the plan of correction via documentation in the monthly Incident Management Meetings. The Assistant Vice President, in conjunction with the Program Director, will ultimately be responsible for the correction and elimination of the deficient practice related to W155.



483.450(b)(4) STANDARD
MGMT OF INAPPROPRIATE CLIENT BEHAVIOR

Name - Component - 00
The use of systematic interventions to manage inappropriate client behavior must be incorporated into the client's individual program plan, in accordance with 483.440(c)(4) and (5) of this subpart.

Observations:


Based on incident report review, record review, and staff interview, it was determined the facility failed to provide effective and consistent Behavior Support Action Plan (BSP) interventions addressing one individual's elopement behavior. (Individual #1)

The findings included:

A. Individual #1

1. The record of Individual #1 was reviewed on January 17 and 18, 2024. This individual's diagnoses included: Mild Intellectual Disability; Adjustment Disorder; Depression; Anxiety; and Suicidal Ideations.

2. Staff interview with the Qualified Intellectual Disabilities Professional (Q.I.D.P.) and Behavior Program Specialist on January 24, 2024, at 1:00 PM, revealed Individual #1 had engaged in elopement behaviors/elopement threats from July 1, 2023 to January 24, 2024. One of the incidents occurred "in the last few months" in which Individual #1 threatened to elope from the facility van while it was in motion. This necessitated the trip to be interrupted and the van returning to the facility.

3. Staff interview with the Assistant Supervisor on January 18, 2024, at 1:00 PM, revealed Individual #1 had engaged in elopement behaviors/elopement threats on a consistent basis from June 1, 2023 to the present. The Assistant Supervisor revealed that that Individual #1 has made threats to elope, as well as actually physically approaching the facility exit on several occasions.

B. Interview with the Program Manager on January 24, 2024, at 11:00 AM, confirmed that Individual #1 exhibits elopement behaviors and makes threats of such on a consistent basis.





































Plan of Correction:

W289 Management of Inappropriate Client Behavior
The deficient area involves Individual #1's Behavior Support Plan, and the lack of "elopement threats/behavior" as a target behavior, and interventions to be implemented to address this behavior.

Individual #1 is a cancer patient who underwent a right breast mastectomy in 2022, and has had many interventions and follow-up to present. Her cancer appears to be in remission, however the events and experience for Individual #1 have had a detrimental effect on her emotions and behavior. She displays an array of "odd" behaviors that have been "grouped" into two target behaviors. Individual #1 is on a Behavioral Support Plan to address:
- Anxious Behaviors
- Delusional thought Processes

She is followed by Dr. Malik, Psychiatrist and is prescribed Abilify 10mg HS. There have been some psychotropic medication "holds" agreed upon by the psychiatrist and primary physician due to some systemic effects on Individual #1 (kidneys), however due to some "stability" psychiatric follow-up may include medication adjustments.

To address the deficient area identified in W289, the facility will implement the following corrective and systematic interventions:

The QIDP, in conjunction with the Interdisciplinary Team will review Individual #1's Behavior Support Plan and include "Elopement Threats/Behaviors" as a target behavior. This behavior was identified as a concern during the complaint investigation and through interviews with staff.

The team will also review "other behaviors" that may help either define "Anxious Behavior" or "Delusional Thought Processes" or isolated "specific behavior(s)". Individual #1 is diminutive and non-violent, but many of her verbalizations are conversations with no one there, threats of violence, or "TV Talk" that blends into "reality". Some of these behaviors have been place into the broad categories noted above.

To address all other individuals who may be adversely affected by the deficient practice, the Interdisciplinary Team will continue to address "behaviors" and Behavior Supports Plans, via monthly Incident Management meetings, Quarterly Staffings and Annual Reviews.

In addition, the facility will monitor progress with the DOH plan of correction via the facility's monthly Incident Management meetings and the Assistant Vice President, in conjunction with the Program Director will be responsible for the plan of correction and elimination of the deficient practice in W289.




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 observations, staff interviews and record review, it was determined that the facility failed to furnish the adaptive equipment to meet the needs of one individual and failed to provide formal training for the use the special device. (Individual #1)

The findings included:

A. Individual #1

1. Observations on January 17, 2024 at 1:00 p.m. and January 18, 2024 at 1:45 p.m. at the day program site, revealed that Individual #1 did not have the use of a special device available. (Hearing aids).

2. Record review of Individual #1 revealed that she was admitted to the facility on April 19. 2019 with hearing aids.

3. Review of Individual #1's current Individual Program Plan indicated that no formal program or supplemental procedure addressing her auditory needs were available in her treatment plan.

4. An interview with Registered Nurse (RN) on January 18, 2024 confirmed that Individual #1 did lose her hearing aids sometime in December of 2023 around the time she went on a trip for a Christmas party. RN stated hearing aids were found four days ago, January 14, 2024, in the facility van. RN also stated that Individual #1 was still not currently wearing the hearing aids because she had an appointment today to get the hearing aids fixed.

B. The facility failed to consistently attempt to have Individual #1 wear hearing aids so as to enhance and maximize independence regarding the use and care of the hearing aids.

C. Interview with the Program Director on January 24, 2024 at 11:00 a.m. confirmed that the facility failed to provide formal training for one individual regarding the proper use of special devices.



















Plan of Correction:


W436 Space and Equipment
The deficient practice includes Individual #1's hearing aids that were lost, then found, and subsequently in need of repair.

The facility failed to furnish, maintain in good repair, and teach Individual #1 how to adequately secure and store her hearing aid(s) so that they were available for daily needs.

To address the deficient area, the QIDP, in conjunction with the Interdisciplinary Team, will implement relevant goal(s) to address Individual#1 securing her hearing aids, and any devices (eye glasses, dentures) that are prescribed for her to enhance her quality of life.

In addition, the Assistant Vice President, in conjunction with the management and clinical team will review agency policies related to adaptive device and personal possessions, implement modifications and in-service all staff on Individual #1's personal possessions and adaptive equipment, and all other individuals who could be adversely affected by the deficient practice.
One in-service in particular will be the agency electronic documentation, Point Click Care where adaptive equipment is identified as to status of wearing and storage.

The monthly Incident Management meeting will be utilized to monitor progress on the plan of correction, namely review/modification of policy, identifying individual goals implemented, etc. the Assistant Vice president, in conjunction with the Program director will ensure successful implementation of the plan of corrections and elimination of the deficient practice.