QA Investigation Results

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

There are  16 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:

A focused fundamental survey visit was completed on May 11 and 12, 2022. The purpose of this visit was to evaluate compliance with the requirements of 42 CFR, Part 483, Subpart I regulations for Intermediate Care Facilities for Individuals with Intellectual Disabilities. The census at the time of the visit was eight, and the sample consisted of three individuals.

Plan of Correction:

483.420(a)(2) STANDARD

Name - Component - 00
The facility must ensure the rights of all clients. Therefore the facility must inform each client, parent (if the client is a minor), or legal guardian, of the client's medical condition, developmental and behavioral status, attendant risks of treatment, and of the right to refuse treatment.


Based on interview with administrative staff and a review of facility records, the facility failed to inform an individual of the attendant risks of treatment and the right to refuse treatment for one of two sample Individuals receiving behavior modifying medications. This practice is specific to Individual #1.

Findings include:

A review of Individual #1's record on 05/12/2022 between 9:00 AM and 11:00 AM revealed a 90-day Physician's order dated 04/20/2022 through 07/18/2022. This physician's order revealed that Individual #1 is prescribed Aripiprazole (Abilify )10 mg tablet daily at 8:00 AM for bipolar disorder and Nuedexta 20mg/10mg capsule twice a day at 8:00 AM and 8:00 PM for bipolar disorder.

Continued record review revealed a document titled Consent to Treatment dated 08/10/2020. This document revealed that consents were obtained for the medications of Aripiprazole (Abilify) 10 mg daily and the Nuedexta 20mg/10mg twice daily, and noted an expiration date of 08/10/2021 for this consent. In further review, there was no evidence that
secured a follow-up consent for treatment post the expiration of the previous consent on 08/10/2021.

Interview with the facility's program director on 05/12/2022 at approximately 10:30 AM confirmed that the facility renews consents for the the use of behavior modifying medications on an annual basis. The program director confirmed that the facility did not obtain consent from Individual #1 for the use of the medications.

Plan of Correction:

Specialist and Health Care Coordinator reviewed physician orders, and obtained Human Rights Consent (HRC) which includes being informed of attendant risks of treatment and the right to refuse treatment for Individual #1 by 5/16/2022.
Completions Date: 5/16/2022
The Qualified Intellectual Disability Professional (QIDP) will have team meetings for all individuals' that reside in the facility to review medical conditions, developmental and behavioral status, reviewing the attendant risks of treatment and right to refuse treatment. The Team will ensure all consents for treatment which includes; date of physician order, date of consent of individual, family/guardian consent, and ensure time limitation of consents are all current (within 365 day time period) and all information is documented accurately through the HRC process.
Completions Date: 7/14/2022
All individuals' current consents will be reviewed and for completeness and accuracy and should include; medication prescribed, dosing levels, medication fact sheet, any attendant risks associated with use or risks in not using medication(s), all treatments currently prescribed, signatures from each individuals consenting to treatment and where applicable, family/guardian/facility Administrator. Additionally as indicated, as indicated HRC and date and time obtained and time limit defined. The Director of Social Service will train Health Care Coordinator (HCC), staff nursing and Program Director, QIDP and Behavior Specialists on process of completing forms and procedures for obtaining individual's consent as well as, all other applicable parties' consent.
All consents will be kept in original form and a copy of consent placed in Point Click Care (PCC).
Training sheets will be completed by Director of Social Service and kept in the house and a copy forwarded to the Training Department.
Completion Date: 7/31/2022
CE # 3 / 4
All individuals physician orders for use of prescription drugs, treatments, and restrictive procedures will be reviewed monthly, for the next 6 months by the QIDP and Health Care Coordinator to assure accuracy and the results of these audits will be recorded on a "Consent Audit Form" submitted to the Director of Social Services. If is found that any consent/form was completed incorrectly or inaccurately, immediate correction must be completed within 72 hours. All discrepancies will be brought to the Administrator's attention by the Director of Social Service.
Completion Date: 12/31/2022
The Director of Nursing will be responsible to complete a quarterly audit for a 12 month time period on all consents and physician orders and forward the audit to the Director of Social Services. The Director of Social Service will alert the Administrator to any discrepancies.
Completion date: 5/31/2023
The Administrator will review all completed audits to ensure completeness and accuracy.
Completion Date: 5/31/2023
CE # 5
Persons responsible : Director of Nursing, Director of Social Service, Health Care Coordinator, QIDP, Behavior Specialist, Program Director and Administrator.