QA Investigation Results

Pennsylvania Department of Health
BARC DEVELOPMENTAL SERVICES INC. ROUTE 313
Health Inspection Results
BARC DEVELOPMENTAL SERVICES INC. ROUTE 313
Health Inspection Results For:


There are  27 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 November 16-17, 2022.
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 six, and the sample consisted of three individuals.












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 interview with facility and administrative staff, the facility failed to ensure privacy during treatment and care of personal needs for one sample Individual. This practice is specific to Individuals #3.

Findings include:

Observations completed on 11/16/2022 from approximately 3:30 PM to 4:15 PM, revealed
that at 3:42 PM survey staff observed Individual #3 exiting her bedroom on a shower chair, being pushed by staff. Individual #2 had a bath towel draped over the front of her body and it was observed that she was naked under the towel. Staff proceeded down the hallway and pushed Individual #3 into the bathroom that had a walk in shower. As this surveyor walked pass the bathroom it was observed that the bathroom door was wide open and Individual #3 was fully naked with staff showering her.

Interview with the House Manager on 11/16/2022 at approximately 3:50 PM, confirmed that staff should have prepared this Individual for showering while in the bathroom, and closed the bathroom door during these personal care activities.

Interview with the Program Director on 11/17/2022 at approximately 8:45 AM, confirmed that the staff should have closed the bathroom door to ensure privacy for this Individual during personal care activities.

















Plan of Correction:

Core Element #1: On 12-01-22 an investigation was started after DOH identified a rights violation.
On 11-17-22, the ICF Program Director retrained the QIDP on the requirement that all individuals must have privacy provided during all treatment and care of personal needs, including when showering. On 11-17-22, the QIDP retrained the Home Manager on the requirement that all individuals must have privacy provided during all treatment and care of personal needs, including when showering. By 12-7-22 the QIDP will retrain all staff on the requirement that all individuals must have privacy provided during all treatment and care of personal needs, including when showering. New staff will be trained as they start working in the home. Documentation will be the Privacy During Personal Care form.

Core Element #2: By 12-15-22, the ICF Program Director, QIDP, Nurse and Home Manager will meet to review everyone that resides at this home and discuss specifically if there are any specific privacy issues or concerns that need to be addressed or initiated in addition to ensuring that privacy is ensure during the provision of all personal care provided by staff. Any suggestions resulting from these meetings will be implemented as appropriate. Documentation will be via IDT Meeting Notes.

Core Element #3: During each shower time, the staff assisting the individual will ensure that the individual is fully covered if unclothed in the hallway area, has the door closed when in the bathroom, has not opened the door when still unclothed, and ensure all other privacy rights related to showering and personal care during hygiene are maintained. Each day, for each individual, at each shower time, staff will document that each individual's privacy rights were respected and ensured. Documentation will be the Individuals Privacy Assurance form.

Core Element #4: Two times per week, the Home Manager will do random and unannounced observations of staff ensuring the privacy of individuals to ensure that their rights are being maintained. If the Home Manager observes any concerns during their observations, they will address them at that time and notify their supervisor. Concerns observed will be documented on the observation form. Documentation will be the Individuals Privacy Observation form completed by the Home Manager.
Three times per month, the QIDP will do random and unannounced observations of staff ensuring the privacy of individuals to ensure that their rights are being maintained. While in the home, the QIDP will review all Individuals Privacy Assurance forms completed by staff since the QIDP's last unannounced observation to ensure that the privacy rights for all individuals have been followed. If the QIDP observes any concerns during their observations, they will address them at that time and notify their supervisor. Concerns observed will be documented on the observation form. Documentation will be the QIDP's signature, date and notes on the Individuals Privacy Assurance forms and the Individuals Privacy Observation forms completed by the QIDP.

Core Element #5: Once per month, the ICF Program Director will review the Privacy During Personal Care forms, IDT Meeting Notes, Individuals Privacy Assurance forms and the Individuals Privacy Observation forms to determine if the documentation indicates that privacy was ensured and as required. If there are any areas of concern, the ICF Program Director will retrain the QIDP and the QIDP will retrain the Home Manager and all staff. Documentation will be the ICF Program Director's signature on each documentation form.



483.460(f)(2) STANDARD
COMPREHENSIVE DENTAL DIAGNOSTIC SERVICE

Name - Component - 00
Comprehensive dental diagnostic services include periodic examination and diagnosis performed at least annually.

Observations:


Based on record review and interview with administrative staff, the facility failed to provide comprehensive dental diagnostic services including periodic examination and diagnosis performed at least annually for one of three sample Individuals. This practice is specific to Individual #1.

Findings include:

A review of Individual #1's record was completed on 11/17/2022 from 9:00 AM to
10:30 AM. This review revealed that this Individual's last dental examination was on 08/11/2021. The report revealed the condition of teeth was very poor, condition of teeth relative to last visit was declining, and the condition of gums relative to last visit was also declining. The summary of this visit noted Individual #1 has severe buccal (sides of the mouth) cavities on all posterior teeth, crowns or extractions were completed on all back teeth. Follow up needed in twelve months.

In further review, it was noted that actions were initiated and the required paperwork for dental work under general anesthesia was completed on 07/19/2022. However, there was no further information to indicate if this paperwork had been processed for scheduling of dental services for Individual #1.

Interview with the facility nurse on 11/17/2022 at approximately 9:40 AM indicated that this interviewee was unable to explain the delay in scheduling the annual dental examination following the submission of the facility's paperwork.







Plan of Correction:

Core Element #1: On 11-17-22, the ICF Program Director retrained the QIDP, Director of Nursing, House Nurse and the Health Care Coordinators on the requirement that individuals must receive comprehensive dental diagnostic services performed at least annually. New staff will be trained as they start working in the home. Documentation will be the Dental requirements retraining form.

Core Element #2: By 12-15-22, the ICF Program Director, QIDP, Nurse, HCC, and Home Manager will meet to review and discuss specifically each person's dental exams and any recommendations that were made. At this time all dentals appointments will be reviewed to ensure that they are not past due. Any issues resulting from these meetings will be addressed immediately. Documentation will be via IDT Meeting Notes.

Core Element #3: During each scheduled monthly IDT meeting, the team will review the upcoming appointments, paying special attention to any dental appointments or follow up that needs to occur. At each meeting the last dental examination and the frequency the individual should be seen (ex. 3 months, 6 months, annually) will be documented under the dental category on the IDT form for each individual residing at this house. Any issues resulting from these meetings will be addressed immediately. After these monthly meetings occur the QIDP will send the IDT documentation to the Director of Nursing for review.

Core Element #4: The Director of Nursing will review the monthly IDT forms within 7 days after each meeting to ensure each individuals dental needs are being followed up on appropriately by the nurse and the HCC's. If the Director of Nursing observes any concerns during their observations, they will address them at that time and notify their supervisor. If Dental appointments are not within the needed time frame the Director of Nursing will ensure they are scheduled immediately. Concerns observed will be documented directly on the IDT form.

Core Element #5: At the end of the month, the ICF Program Director will review the IDT Meeting Notes to ensure all dentals are current. If Dental appointments are not within the needed time frame the ICF Program Director will ensure they are scheduled immediately. If there are any areas of concern, the ICF Program Director will retrain the QIDP and the Director of Nursing. Documentation will be the ICF Program Director's signature on each IDT documentation form.