Initial Comments:
A focused fundamental survey was conducted June 13-14, 2023, to determine compliance with the requirements of the 42 CFR Part 483, Subpart I Regulations for Intermediate Care Facilities. The census during the survey was five and the core sample consisted of three individuals.
Plan of Correction:
483.420(d)(4) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
If the alleged violation is verified, appropriate corrective action must be taken.
Observations:
Based on a review of facility provided incident reports and interview, it was determined that the facility failed to ensure that corrective actions identified were completed. This applied to three of 26 incident reports reviewed. Findings included:
1. A review of facility provided incident reports was completed on June 14, 2023. This review included an incident report dated April 23, 2023, at 6:00 PM, for Individual #3, in which their manual wheelchair "tipped forward due to weight shifting." The incident report indicates that the date that the incident occurred was April 22, 2022, at 9:00 PM, and that nursing staff was not notified of the incident and the individual was not assessed until April 23, 2023, at 4:30 PM. A review of the incident on May 8, 2023, by the Health Services Supervisor stated, "retrain staff on calling care center." This review failed to reveal any documentation that this retraining occurred.
2. A review of facility provided incident reports was completed on June 14, 2023. This review included an incident report dated April 6, 2023, in which Individual #4 had "sun burn to both hands from the wrist down to knuckles." The corrective action for this incident, identified April 6, 2023, indicated that the House Manager (HM) would educate staff on the importance off sunblock to clients. This review failed to reveal any documentation that this retraining occurred.
3. A review of facility provided incident reports was completed on June 14, 2023. This review included an incident report dated March 24, 2023, in which Individual #3 was identified to have a raw spot on their genitalia and that the area was bleeding "a little." The corrective action for this incident, identified March 27, 2023, indicated that the HM would inform staff of the importance of adult incontinence brief changes. This review failed to reveal any documentation that this retraining occurred.
An interview was conducted with the administrator on June 14, 2023, at 11:30 AM. The administrator confirmed that the identified corrective action should have been completed and documented for the above mentioned incidents.
Plan of Correction:Allegheny Valley School Clearview SFR makes its best effort to operate in full compliance with both Federal and State regulations. Nothing included in the Plan of Correction is an admission otherwise.
AVS Clearview SFR has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections contained herein. Please note that AVS Clearview SFR may contest the merits and/or form of any deficiency or finding alleged below and take responsible steps to appeal them.
On April 23, 2023, an incident occurred in the home where individual #3 tipped forward in her wheelchair. The CARE center was not called, and nursing was not alerted to the incident, resulting in a delay of assessment. Corrective Action of retraining the staff on CARE center notifications was not completed at the time of incident report. As a result, on 6/14/23 all direct care staff within the Clearview home were retrained on Handling Medical and Behavioral Concerns in Group Homes. This training outlines that when there is a medical concern or incident requiring medical intervention in the group homes and there is not a nurse within the home, the CARE Center is to be called immediately to avoid delay in treatment. The signed training sheet will be sent to the Administrator by 7/14/23 and maintained by the Administrator.
On 6/20/23 all residential staff in the Clearview home were trained on corrective actions that were listed on internal incident report written on April 6, 2023, for Individual #4 regarding the use of sunblock. Residential staff were also trained on corrective actions for incident report written on 3/24/23 for Individual #3 regarding the importance of adult incontinence brief changes. The signed training sheet will be sent to the Administrator by 7/14/23 and maintained by the Administrator.
The House Manager and Assistant House Manager of the Clearview location were retrained by the Administrator on 6/21/23 regarding Internal Incident Reports. Specific emphasis was placed on the Safety Officer role in completing internal incident reports as well as completion of appropriate training follow-up for corrective actions for internal incidents.
In order to monitor the effectiveness of this training, the Administrator and Incident Manager will meet one time per month for three months to assess any internal incident reports written in the Clearview home. These meetings will occur in July, August, and September of 2023. Assessment will include a review of the incident, corrective actions listed, and assurance that corrective actions were implemented with appropriate staff signature sheets for training. On-going monitoring of internal incident reports will be completed by the administrator.
Additionally, all House Managers, Assistant House Managers/Program Coordinators and Safety Officers were retrained at the monthly House Manager's meeting on 6/19/23. Training included the Safety Officer's role in completing internal incident reports with a focus on corrective actions and appropriate ways of training/retraining staff on any corrective actions stemming from internal incident reports written in the ICF homes. All signed training sheets were collected by the Administrator and will be maintained by the Administrator.
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