QA Investigation Results

Pennsylvania Department of Health
Health Inspection Results
Health Inspection Results For:

There are  31 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 July 20, 21, and 22, 2022, 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 seven and the sample consisted of four individuals. One deficiency were identified as a result of the survey.

Plan of Correction:

483.470(l)(1) STANDARD

Name - Component - 00
There must be an active program for the prevention, control, and investigation of infection and communicable diseases.


Based on observations, documentation review and staff interview, it was determined that the facility failed to ensure an active prevention and control program for COVID 19.
The findings included:
A) The surveyors entered the facility on July 20, 2022, at 11:00 AM. The surveyors did not have their temperature checked and were not asked screening questions by staff. The Health Services Coordinator was interviewed and stated that facility staff should have performed the temperature check and the screening questions.
B) Review of the facility's Residential Services Visitation Policy dated July 15, 2021 revealed that "all visitors will be screened at the front entrance of the home: In addition, this review revealed, "visitors will have their temperatures taken" and "visitors will be asked if they have exhibited any symptoms of COVID -19 in the past 14 days or have been diagnosed with COVID-19 in the past 14 days".
C) The Program Manager (PM) was interviewed on July 22, 2021, at 9:00 am. The PM confirmed that the facility staff had not asked the surveyors the required screening questions for COVID 19, nor had they had their temperatures taken upon entrance to the facility.

Plan of Correction:

The Residential Services Visitation Policy will be reviewed with all staff members working at the ICF. Screening questions will be posted inside the entrance to the ICF, next to the temperature scanner. In addition to the review, a COVID 19 visitor screening demonstration will be conducted to ensure staff understand the expectations of the policy.
This review and training will be completed by the QIDP and monitored by the Program Manager.
The Program Manager will complete random monthly visits to the ICF and request that staff conduct a mock visitor screening. The Program Manager will review results of each monthly visit with the Program Director and complete additional training as needed.
Completion will be: 7/29/2022