QA Investigation Results

Pennsylvania Department of Health
COMMUNITIES OF DON GUANELLA AND DIV PRO AT ROSE TREE ROAD
Health Inspection Results
COMMUNITIES OF DON GUANELLA AND DIV PRO AT ROSE TREE ROAD
Health Inspection Results For:


There are  3 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 September 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 Disabilities. The census at the time of the visit was four, and the sample consisted of two individuals.








Plan of Correction:




483.430(e)(2) STANDARD
STAFF TRAINING PROGRAM

Name - Component - 00
For employees who work with clients, training must focus on skills and competencies directed toward clients' health needs.

Observations:


Based on observation, record review and interview with administrative staff, the facility failed to ensure for employees who work with clients, receive training that focuses on skills and competencies directed toward clients' health needs for one of one sample individual who is experiencing weight loss. This practice is specific to Individual #2.

Findings included:

1. Observations of the breakfast meal was completed on 09/24/2024 from 7:30 AM to 8:15 AM revealed Individual #2 was seated at the dining room table with two other Individuals. Individual #2 was served two banana muffins with syrup on top, a container of yogurt, milk, juice and a cup of hot tea. Individual #2 consumed his entire meal.

Observations of the dinner meal was completed on 09/24/2024 from 5:15 PM to 5:45 PM revealed Individual #2 was seated at the dining room table with two other Individuals. In the center of the table, staff placed two bowls on the table containing cheese ravioli and green beans. Individual #2 served himself five cheese raviolis and green beans filling his plate with the food. Individual #2 consumed his entire meal.

2. A review of the record for Individual #2 was completed on 09/25/2024 from approximately 9:00 AM to 11:00 AM for the period 12/01/2023 (date of admission) to date of survey. This review revealed an annual nutrition assessment dated 12/14/2023 which states he is eating very well, and tolerating his current diet consistency (soft to chew, thin liquids). Goal had been weight maintenance 150-160 pounds, but stated he is lower now.
In the section titled Nutrition Plan of Care/Goals/Interventions it states the following:
"at this time, will lift restrictions on beverages due to weight loss. Will monitor for further weight loss and/or changes in appetite. Goal is no further weight loss."

On a subsequent document submitted by the Nutritionist titled Diet Order Change Form dated 07/10/2024, the following recommendations were noted: "Please order boost plus drink BID at 2pm and in the evening. Give another boost plus drink if he eats less than 50% of a meal. Weigh weekly for now."

A review of physician's orders for Individual #2 revealed an order dated 07/11/2024 for Boost Plus two times a day, at 2:00 PM and 8:00 PM. This order also indicated that Individual #2 should be weighed every Thursday evening for weight management.
The administration of Boost Plus and weekly weights were to be documented on
Individual #2's Medication Administration Record.

A review of the monthly weights for Individual #2 documented in the electronic record under vitals revealed the following:

-12/14/2023: 139.0 pounds
-01/12/2024: 138.0 pounds
-02/16/2024: 133.8 pounds
-02/22/2024: 133.0 pounds
-03/21/2024: 130.6 pounds
-04/11/2024: 130.1 pounds
-05/14/2024: 130.0 pounds
-06/13/2024: 126.5 pounds
-07/11/2024: 122.5 pounds
-08/15/2024: 123.5 pounds
-09/11/2024: 126.0 pounds

A review of the Medication Administration Record for weekly weights for the period 07/11/2024 through the date of the survey revealed that Individual #2's weight was not being recorded as prescribed by the physician every Thursday evening since the order was written on 07/11/2024.

Interview with the Program Director on 09/25/2024 at 9:55 AM confirmed that
Individual #2's weight was not being documented on a weekly basis as prescribed by the physician.























Plan of Correction:

CE 1
Qualified Intellectual Disability Professional (QIDP) will conduct a team meeting for individual # 2. This meeting should review current diet orders, inclusive of snacks/supplements, orders to give supplement if less than 50% of meal consumed, and physician order for weights.
Completion date: 10/31/2024
CE2
The QIDP will conduct team meeting for all others living in the home to review current diet orders, inclusive of snack/supplements, orders to give supplement if less than 50% consumed and if there is physician orders for weights. Review of policy on monthly weights was also reviewed.
Completion date: 11/30/2024
CE 3 /4
The QIDP, Healthcare Coordinator (HCC) and Dietician will retrain all facility staff, nursing staff , residential manager(s) on diets inclusive of weight maintenance programs. Additionally, training will be offered for proper weight management, measuring weights and individual schedules for weights. All weights will be corded as ordered in electronic health record. These trainings will be documented and kept on file.
The dietician, along with the HCC will alert team members and physician to fluctuations in weight +/- 5 pounds. A team meeting will be held to develop a weight plan.
The Assistant Director of Nursing (ADON)/ Director of Nursing (DON) will complete a chart audit of all weights for the next 6 months to ensure completion. The audit will include: recoded weight for each month, whether on not weight gain or loss noted, referral to dietician, physician and IDT/QIDP for further action. These audits will be forwarded to Administrator for review.
Completion date: 4/1/2025
CE 5
Responsible persons: QIDP, dietitian, nurse, HCC, ADON, DON and Administrator
Administrator will oversee corrective action.



483.460(c)(4) STANDARD
NURSING SERVICES

Name - Component - 00
Nursing services must include other nursing care as prescribed by the physician or as identified by client needs.

Observations:


Based on record review and interview with administrative staff, the facility failed to include other nursing care as prescribed by the physician or as identified by client needs for one of one Individual with undesirable weight loss. This practice is specific to Individual #2.

Findings included:

A review of the record for Individual #2 was completed on 09/25/2024 from approximately 9:00 AM to 11:00 AM for the period 12/01/2023 (date of admission) to date of survey.
This review revealed an annual nutrition assessment dated 12/14/2023 which states he is eating very well, and tolerating his current diet consistency (soft to chew, thin liquids). Goal had been weight maintenance 150-160 pounds, but stated he is lower now at 139 pounds. In the section titled Nutrition Plan of Care/Goals/Interventions it states the following: "at this time, will lift restrictions on beverages due to weight loss. Will monitor for further weight loss and/or changes in appetite. Goal is no further weight loss."

Further review revealed a document submitted by the Nutritionist titled Diet Order Change Form dated 07/10/2024 included the following recommendations: "Please order boost plus drink BID at 2pm and in the evening. Give another boost plus drink if he eats less than 50% of a meal. Weigh weekly for now."

A review of physician's orders for Individual #2 revealed an order dated 07/11/2024 for Boost Plus two times a day, at 2:00 PM and 8:00 PM. This order also indicated that Individual #2 should be weighed every Thursday evening for weight management.
The administration of Boost Plus and weekly weights were to be documented on
Individual #2's Medication Administration Record.

A review of Individual #2's Medication Administration Record for the period 07/11/2024 to present, revealed there were no weekly weights obtained as ordered by the physician.

Interview with the Director of Nursing on 09/25/2024 at 10:00 AM confirmed there were no weekly weights collected for Individual #2.














Plan of Correction:

CE 1
The Qualified Intellectual Disability Professional (QIDP) will conduct a team meeting for individual #1 to review current diet orders inclusive of weight management goal. The team will review all pertinent guidelines to be followed to ensure weight stability. The review will clarify the physician orders for the frequency of weight measurement, recording of the weights in the electronic record and notification of fluctuations in weight for individual # 1 and the notification of changes + / - 5 pound to the physician and dietician monthly.
Completion date: 10/15/2024
CE 2
The Qualified Intellectual Disability Professional (QIDP) will conduct a team meetings for individual all other individuals living in the home to review current diet orders inclusive of weight management goal. The team will review all pertinent guidelines to be followed to ensure weight stability. The review will clarify the physician orders for the frequency of weight measurement, recording of the weights in the electronic record and notification of fluctuations in weight for individual # 1 and the notification of changes + / - 5 pound to the physician and dietician monthly.
Completion date: 10/31/2024
CE 3
The Dietician, along with the Director of Training will provide training to Health Care Coordinator, nurse, QIDP and direct care staff on the importance of weight management as a preventative health measure and following physician orders as written. The training record will be kept on file.
Completion date; 11/15/2024
CE 4
The Program Director will review all diet plan and weights for the next 6 months. The review will be recorded on a monthly weight check audit. These audits will be forwarded to Administrator for review.
The Assistant Director of Nursing/ Director of Nursing will complete chart audits for the next 6 months. These audits will be review individuals' weights recorded in electronic health record, diet plans, physician orders and whether any teams meeting were held related to clients' weight loss or gains. The audits will be forwarded to a
Administrator for review. If it is noted an individual has shown a weight loss or trending downward in weight, the ADON/DON will immediately call for team meeting and notify the Administrator.
Completion date: 4/1/2025


CE 5
Persons responsible: QIDP, Dietician, Director of Training, HCC, Program Director Administrator
The Administrator will direct all corrections action found due to non-compliance.