QA Investigation Results

Pennsylvania Department of Health
BARC DEVELOPMENTAL SERVICES INC. HELLERTOWN AVENUE
Health Inspection Results
BARC DEVELOPMENTAL SERVICES INC. HELLERTOWN AVENUE
Health 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:


A focused fundamental survey visit was completed on March 1 and 2, 2021. 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 five, and the sample consisted of three individuals.













Plan of Correction:




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 interview with the administrative staff, the facility failed to ensure that nursing services perform a review of individual health status by direct physical examinations on a quarterly basis for three out of three sample Individuals. This is specific to Individual #1 through #3.

Findings included:

A review of the records for Individuals, #1 through #3, was completed on 03/02/2021 from 9:00 AM until 11:00 AM. These reviews revealed that the facility nurse failed to conduct a review of each of the individual 's health status by direct physical examination on a quarterly basis. Individual #3 is exemplary of this practice:

Individual #3 :

A review of the record of Individual #3 revealed that the health status quarterlies completed for this Individual, dated, 4/28/2020, 07/22/2020, 10/13/2020, and 01/02/2021 revealed the following statement,
"unable to assess due to COVID - 19 ".

Interview with the ICF director and the qualified intellectual disabilities professional on 03/02/2021 at 11:05 AM confirmed that the individuals did not receive a direct physical examination performed by the facility nurse for the four quarters listed above. Continued interview with the Residential Director revealed that the Nurse Manager was unaware that the facility nurse was not conducting the direct physical examinations on a quarterly basis and that the quarterly examinations should have been completed.




























Plan of Correction:

1. The facility nurse that failed to conduct a review of each of the individual 's health status by direct physical examination on a quarterly basis is no longer with the agency. The nurse is not eligible for rehire. Documentation is the associate file for the nurse in the Human Resources department.
2. The ICF Program Director will retrain the Nursing Supports Manager and once hired, the facility nurse, on the requirement that the facility nurse must conduct a review of each of the individual 's health status by direct physical examination on a quarterly basis. The physical examination must be thorough and include an assessment completed on site by the nurse that includes vital signs and a physical assessment of the individual. The results of the vital signs and the assessment will be documented and shared with the team. Documentation will be on the ICF Nurse Direct Assessment Requirement Training Form.
3. The ICF Program Director will retrain all facility nurses on the requirement that each facility nurse must conduct a review of each of the individual 's health status by direct physical examination on a quarterly basis. The physical examination must be thorough and include an assessment completed on site by the nurse that includes vital signs and a physical assessment of the individual. The results of the vital signs and the assessment will be documented and shared with the team. Documentation will be on the ICF Nurse Direct Assessment Requirement Training Form.
4. Once per month, the facility nurse, or another assigned nurse, will personally complete vital signs and a direct physical examination for each individual residing in the home. The completion of the vital signs and direct physical examination will be documented. Documentation will be the ID note completed by the nurse to document the assessment and vital signs.
5. Once per quarter, the facility nurse, or another assigned nurse, will complete the nursing section of the 90 Day Review, and at the year mark, the Individual Program Plan, and include the results of a direct physical assessment that includes vital signs taken by that nurse. The completion of this document will occur no more than 90 days from the completion of the last document. The facility nurse will submit the completed 90 Day Review / Individual Program Plan to the Nursing Supports Manager within two business days of the meeting. Documentation will be the 90 Day Review and the Individual Program Plan.
6. The Nursing Supports Manager will review the 90 Day Review / Individual Program Plans that are received from the facility nurse immediately upon receipt. The Nursing Supports Manager will ensure that a direct physical assessment is documented as occurring in the 90 Day Review / Individual Program Plan and that vital signs were taken. If a direct physical assessment did not occur or vital signs were not taken, the Nursing Supports Manager will immediately ensure that these are completed and that performance management steps are taken. Documentation will be the 90 Day Review / Individual Program Plan.
7. Once per month, the ICF Program Director will review all ID notes completed by the nurse to document direct physical assessments and any 90 Day Reviews / Individual Program Plans that occurred that month to ensure that all required direct physical assessments and vital signs were completed as required by the facility nurse. Any missing direct physical assessments will immediately be brought to the attention of the supervisor of the facility nurse so that the direct physical assessment can immediately occur and so that performance management steps can be taken. Documentation will be the Direct Physical Assessment Tracking Form.
8. All Documentation will be kept in a Plan of Correction binder in the ICF Program Director's office.



483.470(l)(1) STANDARD
INFECTION CONTROL

Name - Component - 00
There must be an active program for the prevention, control, and investigation of infection and communicable diseases.



Observations:


Based on observation, review of agency policy, and staff interview, the facility failed to ensure that an active program for the prevention and control of a communicable disease was maintained. This practice is specific to the implementation of practice outlined in the facility re-opening plan specific to COVID 19.

Findings include:

1. Observation completed on 03/01/2021 at 7:35 AM revealed that after the survey staff knocked on the front door of the residence, a facility staff person opened the door and was not wearing a face mask. This staff person looked at the surveyor's ID card, then proceed to take a face mask out of his pocket and put it on his face. The staff allowed the surveyor to enter the facility with no other actions completed prior to entry.

2. A review of the facility's re-opening plan titled COVID Policy and Procedures, dated 08/12/2020, revised 02/09/2021, was completed on 03/01/2020 from 9:50 until 11:00 AM. This policy revealed the following information under the Cloth Mask/Surgical Mask and Visits with the Individuals sections of this policy;
"Cloth Mask/Surgical Mask section
1. All staff working with all Individuals in any capacity are required to wear a cloth mask, unless COVID testing is pending or a positive result exists, in which case an N95 or KN95 mask is provided.
2. Cloth mask/surgical masks are to be worn at all times, unless eating and drinking.

Visits with Individuals
4. A screening process will take place by staff which includes an assessment of symptoms of COVID 19 and taking of each visitors' temperature.
8. Hand sanitizer will be provided upon arrival and is required to be used by visitors."

3. Interview with the qualified intellectual disabilities professional (QIDP) on 03/01/2021 at approximately 11:45 PM confirmed that staff had been trained in the facility's Covid Policy and Procedures and should have been wearing a mask, and that this surveyor should have been screened for symptoms of COVID 19 prior to entering the facility.

































Plan of Correction:

1. The QIDP will re-train all staff on the active program for the prevention and control of a communicable disease in place within BARC Developmental Services in response to COVID-19. Particular emphasis will be paid to the sections containing information on the requirement that all staff working with all Individuals in any capacity are required to wear a cloth mask, unless COVID testing is pending or a positive result exists, in which case an N95 or KN95 mask is provided, and that the cloth masks are to be worn at all times (unless the staff is actively eating or drinking.) Additionally, the retraining will include specific information on the requirement to screen any and all visitors to the home by following the process in place at every BARC Developmental Services location of taking the visitor' temperature and assessing the visitor for symptoms of COVID-19. The retraining will include the information that staff are required to ensure that visitors use hand sanitizer before entering the home. Documentation will be the sign off for the COVID 19 BARC Developmental Services Residential COVID Policy and Procedures Retraining Form.
2. Performance Management steps have been completed for the workers on shift when the surveyor arrived at which time the screening process was not completed and masks were not in use. Documentation is the file for each worker.
3. Twice weekly the Home Manager will arrive unannounced and at unplanned times when not expected at the home to observe staff. The Home Manager will document the use of the arrival procedure monitoring process to ensure staff are taking temperatures, screening for COVID symptoms and ensuring sanitizer use. The Home Manager will ensure staff are wearing masks for the entire length of the visit including immediately upon arrival when the Home Manager was not expected. Any procedures not being followed will be documented and performance management steps will be taken. Documentation will be the COVID Arrival and Mask Use Observation Form.
4. Twice weekly the Program Manager will arrive unannounced and at unplanned times when not expected at the home to observe staff. The Program Manager will document the use of the arrival procedure monitoring process to ensure staff are taking temperatures, screening for COVID symptoms and ensuring sanitizer use. The Program Manager will ensure staff are wearing masks for the entire length of the visit including immediately upon arrival when the Program Manager was not expected. Any procedures not being followed will be documented and performance management steps will be taken. Documentation will be the COVID Arrival and Mask Use Observation Form.
5. Once monthly the Program Director will review all documentation associated with this plan of correction to ensure that all reviews are occurring as required. Any missing documentation or incorrect documentation will be immediately addressed with the associate responsible and documented. Documentation will be via the Program Director Oversight Review Form.
6. All Documentation will be kept in a Plan of Correction binder in the ICF Program Director's office.