QA Investigation Results

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


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Initial Comments:


A focused fundamental survey was conducted on July 9, 10, and 11, 2024, 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 three individuals. Two deficiencies were identified as a 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 facility incident report review, it was determined facility staff failed to report an allegation of potential abuse in a timely manner to facility administration for one individual residing in the facility. (Individual #1)

Findings included:

1. Individual #1

a. Review of a facility investigation report and staff interview revealed an incident of potential verbal abuse involving this individual had occurred on September 8, 2023 on second shift. The allegation was not reported to facility administration until September 18, 2023, ten days after the alleged incident of verbal abuse occurred. Interview with the Qualified Intellectual Disabilities Professional (QIDP) on July 10, 2024 revealed the alleged incident of verbal abuse was determined to be confirmed.


2. The QIDP was interviewed at 2:30 pm on July 10, 2024. During the interview the QIDP confirmed the above-mentioned findings.






Plan of Correction:

Plan of Correction:
The incident of failed reporting in a timely matter noted on Individual #1 was discussed with the responsible staff member. 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.

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. In addition, the supervision levels as stated in the IHP for each individual will be reviewed by all staff members. This review and training will be completed by the QIDP and monitored by the Program Manager.

The continual review of the importance of immediate reporting and management at monthly staff meetings will prevent a future incident on the indicated individual, 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 by utilizing the CSG corrective action form when indicated, this will be followed by the Program Supervisor and monitored by the Program Manager.



483.460(c)(3)(iii) STANDARD
NURSING SERVICES

Name - Component - 00
Nursing services must include, for those clients certified as not needing a medical care plan, a review of their health status which must be on a quarterly or more frequent basis depending on client need.

Observations:


Based on record review and staff interview, it was determined that the facility failed to ensure nursing physical examinations were conducted on at least a quarterly basis. This was noted for two individuals in the facility (Individuals #2 and #3).

Findings included:

1. Individual #2

a. A review of Individual #2's record was reviewed on July 9-11, 2024. This review revealed that Individual #2 had a nursing physical exam on July 18, 2023. The next physical exam was conducted on January 20, 2024, a gap of 6 months.

2. Individual #3

b. A review of Individual #3's record was reviewed on July 9-11, 2024. This review revealed that Individual #3 had a nursing physical exam on July 30, 2023. The next physical exam was conducted on January 20, 2024, a gap of 6 months.

C. The Qualified Intellectual Disabilities Professional (QIDP) was interviewed at 2:30 pm on July 10, 2024. During the interview the QIDP confirmed the above-mentioned findings.






Plan of Correction:

A Quarterly Nursing Assessment Form has been implemented through our Electronic Health Records System (Welligent) to ensure that all nursing physical examinations are completed on a quarterly basis.
This will be monitored on a monthly basis by the Health Services Coordinator. The Health Services Coordinator will monitor the due dates and each LPN will be notified as a reminder two weeks prior to the quarterly IHP review. The LPN's will be re-trained on how to complete the form in Welligent. The HSC reviewed the protocol with the LPN's. This will be completed on 7/17/2024.