QA Investigation Results

Pennsylvania Department of Health
ELWYN OF PENNSYLVANIA AND DELAWARE - SUN CENTER
Health Inspection Results
ELWYN OF PENNSYLVANIA AND DELAWARE - SUN CENTER
Health Inspection Results For:


There are  28 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:


A focused fundamental survey was conducted on March 11 and 12, 2021. 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 eight, and the sample consisted of four individuals.












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 a review of facility documentation, record review, and interview with facility staff, the facility failed to ensure that all alleged violations of mistreatment, neglect and abuse are thoroughly investigated for one of one sample individual with an allegation of abuse. This practice is specific to Individual #4.

Findings include:

1. A review of the incident reports and investigations for the period from 03/2020 to 03/01/2021, was completed on 03/11/2021 between 9:00 AM and 12:00 PM. This review noted an incident report dated 07/31/2020 at 3:00 PM. This incident report stated "That [Individual #4], while in the supervisor's office at the [facility], [Individual #4] showed me his pinky and said 'Look.' I witnessed that Individual #4's right pinky was bruised and swollen. When I asked [Individual #4] how he got hurt he said, 'I don't know.' [Individual#4] was taken to the ER, diagnosed with a fracture in the right pinky finger."

An investigation was initiated on 08/01/2020 at 08:06 AM, to determine a cause of a fracture to Individual #4's right pinky finger. A review of the investigation packet documentation, dated 8/10/2020, revealed a witness statement, dated 08/03/2020 at 11:25 AM by the qualified intellectual disabilities professional (QIDP). This witness stated that "[Supervisor] took the key and I followed her to my office. I closed the door stayed in my office. Periodically, I heard Individual #4 making noise. The staff yelled at him multiple times." Continued review of the investigation report revealed a section titled Evidence summary. Under this section of the investigation report it states the following; "[Supervisor] took the key. She and the [QIDP] went to the Q office, unlocked the door, [QIDP] entered and closed the door. He periodically heard Individual #4 making noise and staff yelling at him multiple times."

In further review of facility documentation, there was no evidence that an investigation was completed regarding the allegation of verbal abuse stated by the QIDP in his witness statement.

Interview with the director of quality improvement on 03/11/2021 at approximately
2:00 PM, confirmed that there was no further investigation completed regarding the allegation of verbal abuse for Individual #4.
































Plan of Correction:

CE#1:
The allegation of verbal abuse was assigned for investigation on 3/15/21. A wrap up meeting will be scheduled within 30 days of the assignment to discuss the findings of the Certified Investigator. The Admin Review Team will discuss the results of the investigation and determine corrective actions as identified during the wrap up meeting.
-Person Responsible: Director of Quality Improvement
-Completion Date: 4/15/21
A copy of the final investigation report, completed Administrative Review and related corrective actions will be placed in the POC binder
-Person Responsible: Director of Quality Improvement
-Completion Date: 4/15/21

CE#2:
All incident reports and investigations for individuals residing in Sun Center will be assessed by the Associate Director of Quality Improvement for the survey period March 2020 to present to determine if there are any areas of concern raising to the level of abuse or neglect. The Associate Director will email her findings to the Director of Quality Improvement upon completion of the review. A copy of the email will be placed in the POC binder.
-Person Responsible: Director of Quality Improvement
-Completion Date: 4/15/21

If during the review incidents are identified that rises to the suspicion of abuse or neglect, an investigator will be assigned in an effort to determine the circumstances of the incident. A wrap up meeting will be conducted within 30 days of the assignment. The Administrative Review Team will identify additional corrective actions that need to be implemented as a result of the investigator's findings.
-Person Responsible: Director of Quality Improvement
-Completion Date: 4/15/21

CE #3: All Quality Improvement Specialists and Investigation Specialists will be retrained on recognizing potential allegations identified during an investigation and the requirement to immediately follow up on the concern. A copy of the training will be placed in the POC binder.

-Person Responsible: Director of Quality Improvement
-Completion Date: 3/26/21

A copy of the retraining will be placed in the POC binder.

-Person Responsible: Director of Quality Improvement
-Completion Date: 3/26/21


CE#4:

Within 24 hours of witness interviews, the investigator will scan copies of the witness statements to the assigned point person for review and discussion. If either the point person or investigator identify a concern within the witness statements which cannot be reconciled within the scope of the current investigation, an additional investigation will be assigned.

-Person Responsible: Director of Quality Improvement
-Completion Date: 3/26/21 and ongoing

Concerns that can be reconciled within the scope of the current investigation will be documented in the investigation file. If an additional investigation needs to be assigned, the point person will email the residence's Director of Operations and the Director of Quality Improvement to alert them that an additional investigation is occurring. A copy of the email notification will be maintained in the investigation file.

-Person Responsible: Director of Quality Improvement
-Completion Date: 3/26/21 and ongoing

All Quality Improvement Investigators and point persons will be trained on this new process by the Director of Quality Improvement.

-Person Responsible: Director of Quality Improvement
-Completion Date: 3/26/21


CE#5:

The Executive Director is responsible for monitoring these corrective actions.

-Person Responsible: Executive Director of ICFs/IID
-Completion Date: 4/15/21 and ongoing



483.470(i)(1) STANDARD
EVACUATION DRILLS

Name - Component - 00
The facility must hold evacuation drills at least quarterly for each shift of personnel.



Observations:


Based on a review of facility documentation and interview with administrative staff, the facility failed to hold evacuation drills at least quarterly for each shift of personnel.

Findings include:

A review of fire drill reports for the period from January 2020 to December 2020 was completed on 03/11/2021 between 9:30 AM and 11:00 AM. This review revealed that there was no evacuation drill conducted for the second and third shift of personnel during the fourth quarter (October to December) of 2020.

Interview with the director of quality improvement on 03/11/2021 at approximately 3:00 PM, confirmed that there was no second and third shift evacuation drill conducted during the above noted calendar quarter.



















Plan of Correction:

CE#1:
Fire Drills are held at least quarterly during each shift of personnel. The Fire Drill schedule for Sun Center is created by the Quality Improvement Department to include varied times during each shift per quarter. The schedule is shared with the Security Department who runs the drills.
-Person Responsible: Director of Quality Improvement
-Completion Date: 3/26/21 and ongoing
The assigned Quality Improvement Specialist (QIS) will complete an audit on Sun Center's fire drills to verify the drills were completed at varied times and covered each shift in a quarter. The audit includes reviewing that times were varied and covered each shift of personnel. If a live drill was not held due to the residents being in isolation as a result of positive COVID-19 cases in Sun Center, the QIS will verify that the system was checked, a fire safety training was completed with the individuals, and a fire drill review was completed with staff. Upon completion of auditing the fire drills, the QIS will email the Director of Quality Improvement with the result of the audit.

-Person Responsible: Director of Quality Improvement
-Completion Date: 3/26/21 and ongoing
If fire drills for Sun Center cannot be held due to positive Covid-19 cases within the building and the residents are in isolation, security must still check the system during the designated time as listed on the schedule and document it on the Fire Drill form.
-Person Responsible: Head of Security
-Completion Date: 3/26/21 and ongoing
Security will run fire drills for residences without confirmed Covid-19 cases as scheduled regardless of the status of other buildings on campus.
-Person Responsible: Head of Security
-Completion Date: 3/26/21 and ongoing

If Sun Center is unable to hold an evacuation drill due to Covid-19 positive cases and the residents are in isolation, documented trainings with the individuals will occur. The QIDP will forward a copy of the completed training sign in sheet to the Operations Manager and Quality Improvement Department. The Quality Improvement Department will maintain a copy in the Fire Drill binder. The QIDP will complete this training of all individuals by the 20th of the month.

In addition, fire safety training is required with each shift of personnel. The Operations Manager or designee will complete a shift drill review with staff during the appropriate shift for the month if the building is not able to have a live drill due to COVID-19 positive cases within the residence. The shift drill review will be a verbal run through with staff for the shift the drill was slated for (for example, if it was a 3rd shift drill, 3rd shift staff would all do the verbal walk through).

-Responsible Person: Director of Case Management and Director of Operations
-Completion Date: 3/26/21 and ongoing

CE#2:
Fire Drills are held at least quarterly during each shift of personnel. The Fire Drill schedule for all residences is created by the Quality Improvement Department to include varied times during each shift per quarter. The schedule is shared with the Security Department who runs the drills.
-Person Responsible: Director of Quality Improvement
-Completion Date: 3/26/21 and ongoing

The assigned Quality Improvement Specialist will complete an audit of Fire Drills of all other residences to verify the drills were completed at varied times and covered each shift in a quarter. The audit includes reviewing that times were varied and covered each shift of personnel. If a live drill was not held due to the residents being in isolation as a result of positive COVID-19 cases in the residence, the QIS will verify that the system was checked, a fire safety training was completed with the individuals, and a fire drill review was completed with staff. Upon completion of auditing the fire drills, the QIS will email the Director of Quality Improvement with the result of the audit.

-Responsible Person: Director of Quality Improvement
-Completion Date: 3/26/21 and ongoing

If fire drills for a specific residence cannot be held due to positive COVID-19 cases within the building , the Executive Director of Facility Management will alert the Executive Director of ICF that the drill for that residence is being suspended. The Executive Director of ICF will notify both the Operations team and Quality Improvement Department that the drill is being suspended for the residence due to COVID-29 positive cases and a training/verbal drill run through must occur as outlined above. Security will also perform a system check at the designated time as outlined in the schedule. Residences without Covid-19 cases must run normal fire drills as scheduled.

The Executive Director of Facility Management will also notify the Executive Director of ICF when drills have resumed for that residence. This information will be conveyed to both the Quality Improvement Department and the Operation teams by the Executive Director.

-Responsible Person: Executive Director of Facility Management and Executive Director of ICF
-Completion Date: 3/26/21 and ongoing


CE#3:

Security will submit a copy of the fire drill documentation within 72 hours following the completion of the fire drill. The assigned Quality Improvement Specialist (QIS) reviews fire drill paperwork when they are submitted. If upon review of the documentation, the QIS discovers that a regular fire drill was not held even though there were no positive cases within the residence, the QIS will send an email alerting the Head of Security (and copy the Director of Operations, Director of Quality Improvement and Executive Director), that the regular drill must be completed as scheduled. Upon notification, security will complete the fire drill within 24 hours and submit the documentation to the Quality Improvement Department.

-Responsible Person: Director of Quality Improvement
-Date: 3/26/21 and ongoing

If there are positive cases within a residence, and a copy of the required training/review documentation is not received, the Quality Improvement Specialist will email the QIDP, Operations Manager (OM), Director of Operations (DO) and Director of Case Management (DCM) advising them that documentation of the training/fire drill review has not been received for the residence that is in isolation due to COVID-19 positive cases.

-Responsible Person: Director of Quality Improvement
-Date: 3/26/21 and ongoing


The QIDP is responsible for completing the training with the individuals within 24 hours of being notified the documentation was not received. Likewise, the Operations Manager or designee will complete a fire drill review with staff within 24 hours of being notified the review documentation was not received.

-Responsible Person: Director of Case Management and Director of Operations
-Date: 3/26/21 and ongoing

A copy of the training documentation for the individuals and copy of the fire drill review with staff will be placed in the Fire Drill binder along with the documentation of the system test.

-Person Responsible: Director of Quality Improvement or designee
-Completion Date: 3/26/21 and ongoing


CE#4:

The Operations Manager will confirm the required training with the individuals who live in the residence that is in isolation, is completed by the QIDP within 24 hours of the notification and verify the documentation was submitted to the Quality Improvement Department. The Operations Manager will also confirm that the required staff fire drill review is completed by the designated person within 24 hours of the notification.

-Person Responsible: Director of Operations
-Completion Date: 3/26/21 and ongoing

Disciplinary action will be taken if the QIDP fails to complete the drill training for the individuals when they are in isolation due to positive COVID-19 cases in the residence Disciplinary action will also be taken if the designated person fails to complete the fire drill review with staff.

-Responsible Person: Director of Case Management and Director of Operations
-Completion Date: 3/26/21 and ongoing

If the QIDP assigned to the residence is absent for an extended time, another QIDP or designee will be assigned to complete the training with the individuals.

-Responsible Person: Director of Case Management
-Completion Date: 3/26/21 and ongoing

CE#5:
The Executive Director of ICF is responsible for monitoring these corrective actions.
-Responsible Person: Executive Director of ICFs/IID
-Completion Date: 3/26/21 and ongoing