Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed 3/5/24, Your Child ' s Place was found not to be in compliance with the following requirements of Act 54 of 1999, The Prescribed Pediatric Extended Care Center Act, 35 P.S. Section 449.61.
Plan of Correction:
REQUIREMENT
INDIVIDUALIZED CARE PLAN
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SECTION 15. Regulations. Requirements. (b)(6)
Each child shall have an individualized care plan which is designed by the attending physician; the PECC treatment team; a parent or legal guardian; and, when appropriate, the child. The care plan shall be reviewed at least monthly and revised as the child's care needs change. Staffing shall be adequqate to provide for the needs of each child as identified on the child's care plan.
Observations:
Based on medical record (MR) reviews and an interview with the Administrator (EMP1) the agency failed to ensure accurate documentation to reflect the services provided as ordered in the plan of care for three (3) of five (5) MRs reviewed. (MR1, 3, and 4)
Findings include:
A medical record review conducted on 3/4/24 between approximately 2:20 pm to 3:30 pm of MR ' s 1 and 2 revealed:
MR1: Enrollment Date: 6/6/22, 2-year old child with a primary diagnosis of Hypoxic Ischemic Encephalopathy and G-tube [gastric feeding tube] dependence.
MR1 Orders for January 2024 Plan of Care included: " Medical Day Care Services provided by Registered Nurse ...weigh weekly. " During a review of MR1 ' s documentation titled Daily Report for the period between 1/9/24 - 1/24/24 it was determined that weekly weights were not documented.
A medical record review conducted on 3/5/24 between approximately 10:00 am to 11:00 am of MR ' s 3-5 revealed:
MR3: Enrollment Date: 8/15/23, 1-year old child with a primary diagnosis of Short Bowel Syndrome, intestinal failure, and G-tube [gastric feeding tube] in place.
MR3 Orders for January 2024 Plan of Care included, " Medical Day Care Services provided by Registered Nurse ...Weekly weight/height. " During a review of MR3 ' s documentation titled Daily Report it was determined that height was not recorded along with the weight in the Baseline Nursing Assessment.
MR4: Enrollment Date: 9/27/23, 4-year old child with a primary diagnosis of dysphagia [difficulty swallowing], silent aspiration, and gastroparesis [delayed stomach emptying].
MR4 Orders for January 2024 Plan of Care included, " Medical Day Care Services provided by Registered Nurse ...Weigh weekly. " During a review of MR4 ' s documentation titled Daily Report between the period of 1/2/24 - 1/31/24 it was determined that a weekly weight was not documented.
During an interview with EMP1 (Administrator) on 3/5/24 at approximately 12:00 pm the findings were reviewed and verified. It was determined that the agency documentation did not contain an area for documenting a child ' s height/length and that weights were not recorded per the ordered frequency in MRs 1, 3, and 4.
Plan of Correction:The Clinical Director created special forms to record weights and heights for each child. There are 4 forms created:
1. Monthly Height
2. Weekly Height
3. Monthly weight
4. Monthly weight
These forms will be required of all staff to be used and staff will sign off on acknowledgment of forms.
March 19 was implementation of forms and staff acknowledgment sheets will be signed no later than 3/26/24. (This date is the next time the PRN nurse is scheduled)
As well the Clinical Director updated the Quality Assurance Audit on 3/14/24 and trained the Nurse who comes to do the quarterly quality audit on Observation 0013. She will now specifically audit for the Height and Weight requirement on each child's Care Plan and monitor the forms to be certain all staff are charting and maintaining height and weight requirements per the care plan.
Director will be responsible for monitoring the forms/ charts for proper documentation and disciplinary action will take pace for any staff who does not comply with requirement.
REQUIREMENT
POLICIES AND PROCEDURES
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SECTION 15. Regulations. Requirements. (b)(12)
The director of the PECC shall assure that the governing body has developed, approved and implemented policies and procedures regarding the operation of the PECC. At a minimum, the PECC shall have policies and procedures on the prevention, reporting and investigation of abuse, delivery of medical and therapeutic services, control and delivery of pharmaceutical service and prevention of incidents and accidents.
Observations:
Based on a review of Medical Records (MR) and interviews with the agency Administrator (EMP1), the agency did not maintain a policies or procedures for the delivery of medical/therapeutic services provided for three (3) of five (5) MRs reviewed. (MRs 2, 3, and 5)
Findings include:
A medical record review conducted on 3/4/24 between approximately 2:20 pm to 3:30 pm of MR ' s 1 and 2 revealed:
MR2: Enrollment date: 2/25/21, 6-year old child, primary diagnosis of Extreme Prematurity. MR2 Orders for December 2023 Plan of Care read, " 23. Nutritional Requirements ...Aspiration Precautions. Monitor for signs and symptoms of aspiration and feeding difficulties. ... "
During an interview with EMP1 (Administrator) on 3/5/24 at approximately 10:00 am it was determined that the agency did not have a policy or procedure outlining or defining the provision of Aspiration Precautions.
A medical record review conducted on 3/5/24 between approximately 10:00 am to 11:00 am of MR ' s 3-5 revealed:
MR3: Enrollment Date: 8/15/23, 1-year old child, primary diagnosis of Short Bowel Syndrome, with related diagnoses of Congenital Gastroschisis [infant born with intestines outside of the abdomen], Intestinal failure, and G-tube (gastric feeding tube) in place.
MR3 Orders for January 2024 Plan of Care read, " 27. Orders for Discipline and Treatments ...Weekly and PRN [as needed] sterile dressing change to central venous catheter ...TPN [Total Parenteral (Intravenous) Nutrition] and Lipids combined to infuse 24 hours at a rate of 22.1 ml/hr ... " MR3 contained a document titled Daily Report dated 1/29/24 noting a TPN bag change at 1505. Agency did not have a written policy or procedure for administration of TPN or central line dressing changes.
MR5: Enrollment Date: 10/17/23, 2-year old child, primary diagnosis Hypoxic Ischemic Encephalopathy [brain swelling related to low oxygen levels] and related diagnoses of dysphagia [difficulty swallowing], g-tube [gastric tube] feedings, and failure to thrive.
MR5 Orders for January 2024 Plan of Care read, " 24. Orders for Disciplines and Treatments ... Aspiration Precautions - NPO. " Agency did not have a written policy or procedure for Aspiration Precautions.
During an interview with EMP1 (Administrator) on 3/5/24 at approximately 12:00 pm it was determined that a facility policy/protocol for central line care/dressing changes and TPN administration did not exist.
During an exit interview at approximately 12:00 pm the lack of facility policy/protocols for the medical/therapeutic services of Aspiration Precautions, central line care/dressing changes, and TPN administration were discussed and verified with EMP1 Administrator.
Plan of Correction:Moving forward no child will be admitted to the center if there is not a policy on any type of care that is required via a CarePlan. Once the policy is written staff will be trained and demonstrate competency prior to child's enrollment. This process will stop any future policy deficiencies from taking place.
7 policies were written to cover children's needs as follows:
a. Aspiration (covering children with and without G tubes)
b. Central Line Maintenance
c. Central Line Dressing and cap change
d. Administration of Medications via Central Line
e. Obtaining a Blood Sample from a Central Line
f. Accessing and De-accessing Central Lines
g. Total Parental Nutrition
All staff (Nurses and Aide) will be trained on aspiration precautions no later than 3/26/24.
All Nursing staff will be trained on the 6 policies relating to Central Lines and TPN no later than 3/26/24.
These policies will be added to the policy book as well as online for reference of staff at any time.
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