QA Investigation Results

Pennsylvania Department of Health
COMMUNITY SERVICES - WATSONTOWN
Health Inspection Results
COMMUNITY SERVICES - WATSONTOWN
Health Inspection Results For:


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Initial Comments:

A focused fundamental survey was conducted September 28 and 29, 2020, to determine compliance with the Requirements of the 42 CFR Part 483, Subpart I, Requirements for Intermediate Care Facilities. The census during the survey was eight and the sample consisted of four individuals. Two deficiencies were identified as result of the survey.





Plan of Correction:




483.420(d)(2) STANDARD
STAFF TREATMENT OF CLIENTS

Name - Component - 00
The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures.



Observations:

Based on staff interview and investigation report review, it was determined facility staff failed to report two allegations of potential abuse in a timely manner to facility administration for individuals residing at the facility. (Individuals #2 and #3)Findings included:A. Individual # 2
1. Review of a facility investigation and staff interview revealed an incident of potential neglect had occurred on February 24, 2020 at approximately 5:00 a.m. The allegation was not reported to facility administration until February 24, 2020 at 2:15 p.m., approximately 9 hours and 15 minutes after the alleged incident had occurred. Review of the investigation findings revealed the alleged neglect was inconclusive. B. individual #31. Review of a facility investigation and staff interview revealed an incident of potential incident of misuse of client funds was recognized by staff on January 1 ,2020 at approximately 10:00 p.m. The allegation was not reported to facility administration until January 2, 2020 at 7:30 a.m. approximately 9 hours and 30 minutes after the alleged incident had been recognized by staff. Review of the investigation findings revealed the alleged misuse of funds was confirmed.

C. The Program Manager (PM) was interviewed on September 29, 2020 at 11:00 a.m. During the interview the PM confirmed the above-mentioned findings.














Plan of Correction:

The incidents of failed reporting in a timely matter noted on Individual #2 and #3
were discussed with responsible staff members.
The Policy and Procedures for Incident Reporting and Management was reviewed and training was completed by the Program Supervisor. Emphasis on the importance of reporting an incident immediately when observed to the ON-Call Supervisor and procedural management. A written corrective action was issued to responsible staff members.
The staff member responsible for the incident of Individual #2 is no longer an employee with Community Services Group as a result of our policy and procedures for Incident Reporting and Management and Medication Administration.


The Policy and Procedures for Incident Reporting and Management will be reviewed with all staff members working at the ICF. The staff will have an updated on- call phone number list of Program Managers and Program Directors available. This review and training will be completed by the Program Supervisor and monitored by the Program Manager.

Completion Date 10/15/2020

The continual review of the importance of immediate reporting and management at monthly staff meetings will prevent future incidents on the indicated two individuals', as well as, the rest of the individuals that reside in the ICF.
The Program Supervisor will be responsible to ensure all 8 Individuals are free of these types of incidents. The PM is responsible to ensure this process is followed.
CSG will implement the corrective action form when indicated, this will be followed by the Program Supervisor and monitored by the Program Manager.
Completion Date on or before 10/30/2020.



483.460(k)(1) STANDARD
DRUG ADMINISTRATION

Name - Component - 00
The system for drug administration must assure that all drugs are administered in compliance with the physician's orders.



Observations:

Based on incident report review and staff interview, it was determined the facility failed to ensure that two individuals' medications were administered without error. (Individuals #1, and #2)

Findings included:

A. Individual #1

1. On December 7, 2019 Clorazepate was omitted.

2. On January 21, 2020 a PRN order of Lasix was omitted.3. On March 22, 2020 Phenytoin and Clorazepate were omitted.4. On May 15, 2020 Zonisamide was omitted.5. On June 25, 2020 Zonisamide was omitted.6. On June 28, 2020 Clorazepate was omitted.7. On July 27, 2020 Clorazepate and Dilantin were omitted. B. Individual #21. On August 24, 2020 Baclofen was omitted.

C. The above-referenced errors resulted in a total of ten medication administration errors, from December 7, 2019 to August 4, 2020. Individuals #1 and #2 experienced no ill effects as a result of the above-mentioned errors.


D. Interview with the Program Manager (PM) on September 29, 2020, at 11:00 a.m., During the interview the PM confirmed the above-mentioned findings.







Plan of Correction:

The medication omissions noted on Individual #1 and #2 were discussed with responsible LPN's. Medication policy was reviewed, med passes were observed by the HSC, importance of follow through and communication emphasized, and a written corrective action was issued to responsible LPN's.
The Policy and Procedures for Medication Administration will be reviewed with all LPN's working at the ICF. This review and training will be completed by the Health Services Coordinator and monitored by the Program Manager.

Completion Date 10/15/2020.

Using an Observation Checklist, medication passes will be randomly observed by the Health Services Coordinator and monitored quarterly. Each LPN will have at least 2 observations during this time period.
The continual training and the unannounced observations of the licensed personnel in Medication Administration will prevent future medication errors on the indicated two individuals', as well as, the rest of the individuals that reside in the ICF.

The HSC will be responsible to ensure all 8 Individuals receive their medications error free. The PM is responsible to ensure this process is followed.

CSG will implement the corrective action form when indicated, this will be followed by the Health Services Coordinator and monitored by the Program Manager
Completion Date on or before 10/30/2020.