QA Investigation Results

Pennsylvania Department of Health
BARC DEVELOPMENTAL SERVICES INC. ROSENBERGER
Health Inspection Results
BARC DEVELOPMENTAL SERVICES INC. ROSENBERGER
Health Inspection Results For:


There are  21 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:


A focused fundamental survey visit was completed on December 23 and 24, 2020. The purpose of this visit was to evaluate compliance with the requirements of 42 CFR, part 483, Subpart I Regulations for Intermediate Care Facilities for Individuals with Intellectual Disabilities. The census at the time of the visit was five, and the sample consisted of three individuals.










Plan of Correction:




483.440(c)(3) STANDARD
INDIVIDUAL PROGRAM PLAN

Name - Component - 00
Within 30 days after admission, the interdisciplinary team must perform accurate assessments or reassessments as needed to supplement the preliminary evaluation conducted prior to admission.




Observations:


Based on record review and inteview with facility sand administrative staff, the facility failed to perform an accurate assessment within 30 days after admission as needed to supplement a preliminary evaluation conducted prior to admission for two of two sample Individuals who were newly admitted to the facility. This practice is specific to Individuals #1 & # 3.

Findings include:

A review of the records for Individual #1 and #3 revealed both Individuals did not have an assessment completed within 30 days of their admission.
Individual #1 is exemplary of this practice:

Individual #1;

A review of Individual #1's record was completed on 12/24/2020 between 8:00 AM and 10:00 AM revealed that Individual #1 was admitted to the facility on 12/24/2019. Further review of Individual #1's record revealed the a comprehensive functional assessment was not completed until 02/05/2020, 43 days after admission to this facility.

Interview with the qualified intellectual disabilities professional and the Residential Director, on 12/24/2020 at approximately 10:00 AM, confirmed the facility did not completed the comprehensive functional assessment within 30 days of admission.




























Plan of Correction:


1. The Program Director (PD) will revise the ICF Admission procedure to include language that indicates that a comprehensive assessment is required for all newly admitted individuals within thirty days of admission to an ICF/ID home. Documentation will be the revised ICF Admission Checklist.
2. The PD will retrain all Qualified Intellectual Disabilities Professionals (QIDPs) on the requirement that any newly admitted individual is required to have a comprehensive assessment within thirty days of admission to an ICF/ID home. This comprehensive assessment will be based on information obtained during visits, during which time preliminary evaluations, data collection and observations occur. Documentation will be the New Admission Comprehensive Assessment Training sign-in sheet.
3. The Program Director (PD) will revise the ICF Admission procedure to include language that indicates that the emergency placement of an individual in an ICF/ID home does not supersede the need for a comprehensive assessment to occur within thirty days of admission to an ICF/ID home. Documentation will be the revised ICF Admission Checklist.
4. The PD will retrain all Qualified Intellectual Disabilities Professionals (QIDPs) on the requirement that the emergency placement of an individual in an ICF/ID home does not supersede the need for a comprehensive assessment to occur within thirty days of admission to an ICF/ID home. Documentation will be the New Admission Comprehensive Assessment Training sign-in sheet.
5. The PD will oversee the admission process for all ICF individuals, including those in need of emergency placement and those admitted under normal procedures, to ensure that a comprehensive assessment is completed within thirty days of admission to an ICF/ID home. The QIDP will inform the PD when all visits are scheduled and how long they are scheduled to last. Additionally, the QIPD inform the PD if any visits last longer than scheduled. This information will allow the PD to ensure that the timeframe for the completion of the comprehensive assessment remains within thirty days of admission. Documentation will be ID Notes and the completed ICF Admissions Checklist.
6. The PD will do a chart for the next year to track all vacancies within ICF/ID homes and visits and admission dates as well as the date the comprehensive assessment was completed for each individual to ensure that it was completed within thirty days of admission. Documentation will the ICF/IF Vacancy Tracking chart.
7. All Documentation will be kept in a Plan of Correction binder in the PD's office.




483.440(c)(4) STANDARD
INDIVIDUAL PROGRAM PLAN

Name - Component - 00
Within 30 days after admission, the interdisciplinary team must prepare, for each client, an individual program plan.




Observations:


Based on record review and interview with the facility and administrative staff, the facility failed to prepare a Individual Program Plan within 30 days after admission for two of two sample Individuals who were newly admitted to the facility. This practice is specific to Individuals #1 and #3.

Findings include:
A review of the records for Individual #1 and #3 revealed both Individuals did not have an Individual Program Plan completed within 30 days of their admission. Individual #1 is exemplary of this practice:

Individual #1;

A review of Individual #1's record completed on 12/24/2020 between 8:00 AM and 10:00 AM revealed that Individual #1 was admitted to the facility on 12/24/2019. In further review, it was noted that the post admission Individual Program Plan (IPP) was not completed until
03/02/2020, 69 days after admission to this facility.

Interview with the qualified intellectual disabilities professional and the Residential Director, on 12/24/2020 at approximately 10:00 AM, confirmed that Individual #1's IPP meeting did not occur within 30 days of admission.



















Plan of Correction:

1. The Program Director (PD) will revise the ICF Admission procedure to include language that indicates that an Individual Program Plan is required for all newly admitted individuals within thirty days of admission to an ICF/ID home. Documentation will be the revised ICF Admission Checklist.
2. The PD will retrain all Qualified Intellectual Disabilities Professionals (QIDPs) on the requirement that any newly admitted individual is required to have an Individual Program Plan within thirty days of admission to an ICF/ID home. This Individual Program Plan will be based on information obtained during visits, during which time preliminary evaluations, data collection and observations occur. Documentation will be the New Admission Individual Program Plan Training sign-in sheet.
3. The Program Director (PD) will revise the ICF Admission procedure to include language that indicates that the emergency placement of an individual in an ICF/ID home does not supersede the need for a comprehensive assessment to occur within thirty days of admission to an ICF/ID home. Documentation will be the revised ICF Admission Checklist.
4. The PD will retrain all Qualified Intellectual Disabilities Professionals (QIDPs) on the requirement that the emergency placement of an individual in an ICF/ID home does not supersede the need for an Individual Program Plan to occur within thirty days of admission to an ICF/ID home. Documentation will be the New Admission Individual Program Plan Training sign-in sheet.
5. The PD will oversee the admission process for all ICF individuals, including those in need of emergency placement and those admitted under normal procedures, to ensure that an Individual Program Plan is completed within thirty days of admission to an ICF/ID home. The QIDP will inform the PD when all visits are scheduled and how long they are scheduled to last. Additionally, the QIPD inform the PD if any visits last longer than scheduled. This information will allow the PD to ensure that the timeframe for the completion of the Individual Program Plan remains within thirty days of admission. Documentation will be ID Notes and the completed ICF Admissions Checklist.
6. The PD will do a chart for the next year to track all vacancies within ICF/ID homes and visits and admission dates as well as the date the Individual Program Plan was completed for each individual to ensure that it was completed within thirty days of admission. Documentation will the ICF/IF Vacancy Tracking chart.
7. All Documentation will be kept in a Plan of Correction binder in the PD's office.