QA Investigation Results

Pennsylvania Department of Health
COMMUNITIES OF DON GUANELLA AND DIVINE PROVIDENCE AT ROLLING
Health Inspection Results
COMMUNITIES OF DON GUANELLA AND DIVINE PROVIDENCE AT ROLLING
Health Inspection Results For:


There are  13 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:


A focused fundamental survey visit was completed on July 24 and 25, 2024. 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 Dsabilities. The census at the time of the visit was five, and the sample consisted of three iividuals.












Plan of Correction:




483.440(c)(4)(iv) STANDARD
INDIVIDUAL PROGRAM PLAN

Name - Component - 00
The objectives of the individual program plan must be organized to reflect a developmental progression appropriate to the individual.

Observations:


Based on record review and interview with the Qualified Intellectual Disabilities Professional (QIDP), the facility failed to ensure that the objectives of the individual program plan must be organized to reflect a developmental progression appropriate to the individual based on the Individual's current or baseline functional abilities for three of three sample Individuals.
This practice is specific to Individuals #1, #2, and #3.

Findings include:

A review of the records of Individual #1, #2, and #3 was completed on 07/25/2024 from 8:45 AM to 11:30 AM. These reviews revealed that current written training objectives for these individuals were not organized to reflect a developmental progression based on the Individuals' current or baseline functional abilities. Individual #1 is exemplary of this practice.

Individual #1
A review of Individual #1's record revealed a training plan titled Personal Care-1 which was implemented on 06/20/2024. Continued review of this record revealed the following information:
-Long Term Goal: [Individual #1 will independently care for his fingernails.
-Short Term Objective: "After the stated verbal cue, '[Individual #1], let's clean your fingernails.' [Individual #1] will follow his nail care process with 3 PP (Physical Prompts) for 6:8 sessions by 6/20/25."
-Present Behavior: "[Individual #1] currently needs hand over hand assistance to complete care of his fingernails."

Interview on 07/25/2024 at approximately 10:30 AM with the Qualified Intellectual Disabilities Professional (QIDP) confirmed that the information in this section was the summary of the baseline data staff had documented. When asked if there was actual data collection to support the current level of functioning outlined in the summary, this interviewee did not have actual data collection that supported the documentation as listed of skill performance.

In a review of the outlined training plan steps for this skill set, the following training plan goals were listed:
-Step #1: After the verbal cue, [Individual #1] will use a fingernail brush to scrub under his fingernails on right hand for 30 seconds with 3 physical prompts for 6:8 sessions. A review of the data collected for the period from 06/20/2024 to the date of the survey, 07/25/2024 revealed Individual #3 is currently demonstrating completion of this objective with 2 verbal prompts or less.

Subsequent review of the QIDP monthly progress notes revealed the following:
-"June 2024 -[Individual #1] is currently on Step 1...He completed 3 sessions all with 2 VP (verbal prompts). This is a new goal for [Individual #1] ...he is off to a great start so far. He will remain on Step #1 for July."

Interview with the QIDP on 07/25/2024 at approximately 10:45 AM revealed that when asked if this QIDP observes the baseline data being collected, this interviewee responded that she does not, and that she relies soley on the data collection completed by direct care staff in relation to this training program. This interviewee also stated that Individual #1 is a fast learner and acknowledged that she did not take this into account when writing the objectives.

















Plan of Correction:

CE 1
Individuals #1, 2 and 3 will have their functional assessments and current training plans reviewed by the Qualified Intellectual Disabilities Professional (QIDP) to ensure each skill area reflects current entry level determined through review of accurate baseline data. The QIDP will perform observation of goal implementation to ensure staffs' understanding and confirm accuracy of implementation and data. The team Interdisciplinary Team (IDT) will meet to review updated assessments and approve the training plans as written.
All staff will receive training in training plans and proper implementation details.
The QIDP will summarize in monthly progress notes the individual's progress by review of data completed. The note will indicate success, lack of progress or need for revision. If determined the individual is performing task/skill at level that differs from entry level noted on functional assessment, the QIDP will determine what is needed and include this information in monthly report.
Completion date: 8/30/2024
CE 2
The QIDP and IDT will review functional assessments and current training plans for all other individuals who reside at this location. The QIDP along IDT will determine if each skill area reflects current entry level determined through review of accurate baseline data and current data. The QIDP will make necessary revisions if needed.
All staff will receive training in training plans and proper implementation details.
The QIDP will summarize in monthly progress notes the individual's progress by review of data completed. The note will indicate success, lack of progress or need for revision. If determined the individual is performing task/skill at level that differs from entry level noted on functional assessment, the QIDP will determine what is needed and include this information in monthly report.
Completion date: 9/30/2024
CE 3&4
On 7/31/2024 the Administrator conducted training with Program Director, Director of Social Services, QIDP and Assistant Administrator specific to information following annual survey. Highlights of this training included: functional assessments, training program development and tracking, active treatments and the admission process.
The Program Director will review all functional assessments and make any recommendations at time of review. The Program Director will ensure that assessments are an accurate reflection of individual's current functioning and clearly indicate skills areas requiring training programs as priority needs. Program Director will ensure all training programs are written to reflect developmental progression appropriate to the individual.
Completion date: 9/30/2024

The Program Director will review all current and future individuals' functional assessments prior to the annual review date over the next 12-month period and inform the Administrator of any areas found to be problematic immediately. The Administrator will initiate action as needed.
Completion date: 8/1/2025
CE 5
Those responsible for plan of correction include: QIDP, Program Director, Administrator
The Administrator will address all areas found to not meet the requirements of the plan of correction.