QA Investigation Results

Pennsylvania Department of Health
COMMUNITIES OF DON GUANELLA AND DIVINE PROVIDENCE AT BETHEL
Building Inspection Results

COMMUNITIES OF DON GUANELLA AND DIVINE PROVIDENCE AT BETHEL
Building Inspection Results For:


There are  8 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Name - Component - --

Based on an Emergency Preparedness Survey completed on May 27, 2021, it was determined Communities Of Don Guanella And Divine Providence At Bethel was not in compliance with the requirements of 42 CFR 483.475.




Plan of Correction:




483.475(c)(1) STANDARD
Names and Contact Information

Name - Component - --
403.748(c)(1), 416.54(c)(1), 418.113(c)(1), 441.184(c)(1), 460.84(c)(1), 482.15(c)(1), 483.73(c)(1), 483.475(c)(1), 484.102(c)(1), 485.68(c)(1), 485.625(c)(1), 485.727(c)(1), 485.920(c)(1), 486.360(c)(1), 491.12(c)(1), 494.62(c)(1).

[(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:]

(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.

*[For Hospitals at 482.15(c) and CAHs at 485.625(c)] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [hospitals and CAHs].
(v) Volunteers.

*[For RNHCIs at 403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.

*[For ASCs at 416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For Hospices at 418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.

*[For HHAs at 484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For OPOs at 486.360(c):] The communication plan must include all of the following:
(2) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).

Observations:

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness plan including a communication plan containing all the required contact information, affecting the entire facility.

Findings include:

1. Document review on May 27, 2021, at 8:15 a.m., revealed the facility did not have an Emergency Preparedness Communication plan including names and contact information for resident's physicians.

Exit Interview with the QM Coordinator and Director of Maintenance on May 27, 2021, at 9:25 a.m., confirmed the documentation was not available.




Plan of Correction:

EP binder was updated to include Client profiles with physician contact information and phone numbers.
Quality management team and House Manager will maintain all emergency preparedness binder for updates or changes. binder checks will be completed by house manager.


Initial Comments:
Name - DON GUANELLA HOME @ BETHEL Component - 01

Facility ID# 24181101
Component 01
Don Guanella Homes @ Bethel

Based on a Medicaid Recertification Survey completed on May 27, 2021, at Communities Of Don Guanella And Divine Providence At Bethel, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing ICF/IID Health Care Occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).

This is a one story, Type V (0,0,0), unprotected wood frame construction, with a basement and an attic crawl space, which is fully sprinklered.

State plans approved as Prompt.



Plan of Correction: