QA Investigation Results

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


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Initial Comments:


A focused fundamental survey visit was completed on May 2 and 3, 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:




483.410(c)(1) STANDARD
CLIENT RECORDS

Name - Component - 00
The facility must develop and maintain a recordkeeping system that documents the client's health care, active treatment, social information, and protection of the client's rights.

Observations:


Based on review of facility records and documentation and interview with administrative and facility staff, the facility failed to develop and maintain a recordkeeping system that documents the client's health care, active treatment, social information, and protection of client's rights
.that is an actual and functional representation of the actual experience in the facility, for two of two sample Individuals. This practice is specific to Individuals #1 and #2.

Findings include:

A review of the records of Individual #1 and Indvidual #2 was completed on 05/03/2024 from approximately 8:30 AM to 11:30 AM. In a review of the section titled Physician Orders, [document that outlines current diagnosis, prescribed medication and treatments, and any ancillary care actions required by the physician], the last document within the record are as follows:

Individual #1:
The last physician's orders available within the record was dated 04/19/2023. There were no updated Physician's 90 Day Reviews in the record for the period 07/2023 to the date of the survey, 05/03/2024.

Individual #2
The last physician's orders available within this record was dated 05/02/2023. There were no additional Physician's 90 Day Reviews in the record for the period 08/2023 through the date of the survey, 05/03/2024.

Interview with the Director of Nursing on 05/03/2024 at approximately 11:10 AM indicated that the facility practice was to complete renewal/update of physician orders on a 90 day basis. This interviewee also confirmed. the above findings and also stated that there were no current physician orders for the other individuals in the residence

When further questioned why this practice had not remained in effect, this interviewee indicated that the practice was not maintained since July 2023 at which time the previous nursing staff person assigned to this faiclity had left employment at this agency. This interviewee was unable to indicate why the records were not current to reflect an accurate representation of the Indvidual's treatment experience within the facility.

















































Plan of Correction:

C1:
Program acknowledges that the last Physician's order in Individual #1 chart was on 04/19/2023 and that there were no additional Physician's 90 Day reviews from 7/2023 through the date of the survey, 05/03/2024. Moving forward, Individual #1's Physician's 90-Day Review will be completed by 05/31/2024 . By 06/05/2024, the Director of Nursing or designated nurse will fax the review to the Physician's office for review and sign off and will file the fax confirmation in Individual #1 chart. If the signed Physician's 90-Day Review is not returned by 06/19/2024, the Director of Nursing or designated nurse will contact the physician office within one week and arrange to physically pick up the signed review. The Director of Nursing or designated nurse will document all attempts to retrieve documents and file in Individual #1 chart. The Director of Nursing or designee will file the updated physician's order in Individual #1 chart. The Director of Nursing or the designated nurse, in partnership with the Qualified Intellectual Disabilities Professional (QIDP) will schedule all future Physician's 90-Days Reviews for Individual #1 on the Microsoft Outlook calendar with calendar reminders of upcoming 90-day reviews.

Program acknowledges that the last Physician's order in Individual #2 chart was 05/2/2023 and that there were no additional Physician's 90 Day reviews from 08/2023 to date of the survey on 05/3/2024. Moving forward, Individual #2's Physician's 90-Day Review will be completed by 5/31/2024 By 06/05/2024, the Director of Nursing or designated nurse will fax the review to the Physician's office for review and sign off and will file the fax confirmation in Individual #2 chart. If the signed Physician's 90-Day Review is not returned by 06/19/2024, the Director of Nursing or designated nurse will contact the physician office within one week and arrange to physically pick up the signed review. The Director of Nursing or designated nurse will document all attempts to retrieve documents and file in Individual #2 chart. The Director of Nursing or designee will file the updated physician's order in Individual #2 chart. The Director of Nursing or the designated nurse, in partnership with the QIDP will schedule all future Physician's 90-Days Reviews for Individual #2 on the Microsoft Outlook calendar with calendar reminders of upcoming 90-day reviews.


C2:
For current ICF Individuals: The Qualified Intellectual Disability Professional (QIDP) with the designated nursing staff reviewed all other individual charts on 5/24/2024 and acknowledge that all charts had outdated physician's order. The Director of Nursing or the designated nurse will complete the 90-Day Physician's Review by 06/15/2024. By 06/22/2024, the Director of Nursing or designated nurse will fax the reviews to the Physician, and have the Physician review and sign off the reports. Fax confirmations will be filed in every individual's chart. If the signed Physician's 90-Day Review is not returned by 06/28/2024, the Director of Nursing or designated nurse will contact the physician office within one week and arrange to physically pick up the signed review. The Director of Nursing or designated nurse will document all attempts to retrieve documents and file in the Individual's chart. The Director of Nursing or designated nurse will file all current physician's orders in the Individual charts. The Director of Nursing or the designated nurse, in partnership with the QIDP will schedule all future Physician's 90-Days reviews for current individuals on the Microsoft Outlook calendar with calendar reminders of upcoming 90-day review.

C3
For future ICF candidates: All new admissions will be required to have their Physician's Orders available in the chart by the first day of admission into the program. The Director of Nursing or designated nurse will coordinate with the discharging placement to obtain all the physician's orders. The Director of Nursing or the designated nurse, in partnership with the QIDP will schedule all future Physician's 90-Days reviews on the Microsoft Outlook calendar with calendar reminders of upcoming 90-day review.

C4:
Quarterly, the Qualified Intellectual Disabilities Professional (QIDP) will review the Individuals' charts for updated Physician's 90-Day Reviews and evidence of a physician's approval. The QIDP will email to the Director of Nursing or designated nurse for any missing or incomplete Physician 90-Day Reviews within one week of the review. Within one week of email communication, the Director of Nursing or designated nurse will correct and fax the review to the physician's office for review and sign off and will file the fax confirmations in the individuals' chart. If the signed Physician's 90-Day review is not returned within 2 weeks of it being faxed to the physician's office, the Director of Nursing or designated nurse will contact the physician office within one week and arrange to physically pick up the signed review. The Director of Nursing or designated nurse will document all attempts to retrieve documents and file in the individual's chart. The Director of Nursing or designated nurse will file all current physician's orders in the Individual chart.
In addition to the QIDP reviewing the charts, the Senior Director of Quality Improvement or Quality Improvement designee will also review for compliance utilizing an audit tool during their scheduled Utilization Review on 08/06/2024. The Senior Director of Quality Improvement or Quality Improvement designee will email all review finding by 08/13/2024.
C5:
The Director of Nursing is responsible for execution and tracking of activity completion for this citation. Within one week of discovery, The Director of Nursing will communicate any areas of non-compliance and follow up steps taken to the team via email, including the IDD-Division Director, Senior Director of Quality Improvement, and the Qualified Intellectual Disabilities Professional (QIDP).



483.460(j)(1) STANDARD
DRUG REGIMEN REVIEW

Name - Component - 00
A pharmacist with input from the interdisciplinary team must review the drug regimen of each client at least quarterly.



Observations:


Based on a review of facility records and doucmentation and interview with facility and administrative staff, the facility failed to ensure that a pharmacist, with input from the interdisciplinary team, reviewed the drug regime of each Individual at least quarterly for two of two sample Individuals. This practice is specific to Individual #1 and #2.

Findings include:

A review of the records of Individual #1 and Indvidual #2 was completed on 05/03/2024 from approximately 8:30 AM to 11:30 AM. In a review of pharmacy review documents regarding the drug regime of each Individual, there were no quaterly reviews completed for each Individual as outlined:

Individual #1 ;
This section included a review completed on 04/19/2023. There were no additional Pharmacy Reviews post this date .

Individual #2:

This section included a review completed on 05/02/2023. There were no additional Pharmacy Reviews post this date.

Interview with the Director of Nursing on 05/03/2024 at approximately 11:10 AM confirmed that both Individual #1 and Individual #2 did not have pharmacy review of their medication regime post the dates listed above. This interviewee was unable to indicate why quarterly pharmacy reviews had not been completed post those dates as noted above.












Plan of Correction:

C1:
Program acknowledges that the last Pharmacy Review in Individual #1 chart was on 04/19/2023 and that there were no additional Pharmacy 90 Day Reviews to the date of survey on 05/03/2024. Moving forward, Individual #1's Pharmacy 90-Day Review is scheduled for completion by 05/31/2024. By 06/05/2024, the Director of Nursing or designated nurse will fax the review to the Pharmacist's office for review and sign off and will file the fax confirmation in Individual #1 chart. If the signed Pharmacy 90-Day Review is not returned by 06/19/2024 , the Director of Nursing or designated nurse will contact the pharmacist's office within one week and arrange to physically pick up the signed review. The Director of Nursing or designee will fax pharmacy review to the physician's office for review and approvals of any recommendations. The Director of Nursing or designee with the Qualified Intellectual Disabilities Professional (QIDP) will implement any approved recommendations. The Director of Nursing or designated nurse will document all communications and file in Individual #1 chart. The Director of Nursing or designee will file the updated pharmacy review in Individual #1 chart. The Director of Nursing or the designated nurse, in partnership with the QIDP will schedule all future Pharmacy 90-Days Reviews for Individual #1 on the Microsoft Outlook calendar with calendar reminders of upcoming 90-day review.
Program acknowledges that the last Pharmacy Review in Individual #2 chart was on 05/02/2023 and that there were no additional Pharmacy 90 Day Reviews to the date of survey on 05/03/2024. Moving forward, Individual #2's Pharmacy 90-Day Review is scheduled for completion by 05/31/2024. By 06/05/2024, the Director of Nursing or designated nurse will fax the review to the Pharmacist's office for review and sign off and will file the fax confirmation in Individual #2 chart. If the signed Pharmacy 90-Day Review is not returned by 06/19/2024, the Director of Nursing or designated nurse will contact the pharmacist's office within one week and arrange to physically pick up the signed review. The Director of Nursing or designee will fax pharmacy review to the physician's office for review and approvals of any recommendations. The Director of Nursing or designee, in partnership the Qualified Intellectual Disabilities Professional (QIDP) will implement any approved recommendations. The Director of Nursing or designated nurse will document all communications and file in Individual #2 chart. The Director of Nursing or designee will file the updated pharmacy review in Individual #2 chart. The Director of Nursing or the designated nurse, in partnership with the QIDP will schedule all future Pharmacy 90-Days Reviews for Individual #2 on the Microsoft Outlook calendar with calendar reminders of upcoming 90-day review.

C2:
For current ICF Individuals: The Qualified Intellectual Disability Professional (QIDP) with the designated nursing staff reviewed all other individual charts on 5/24/2024 and acknowledge that all charts had outdated pharmacy reviews. The Director of Nursing or the designated nurse will complete the Pharmacy's 90-Day Review by 06/15/2024. By 06/22/2024, the Director of Nursing or designated nurse will fax the Pharmacy 90-Day Review, and have the Pharmacist review and sign off the reports. Fax confirmations will be filed in every individual's chart. If the signed Pharmacy 90-Day Review is not returned by 6/28/2024, the Director of Nursing or designated nurse will contact the pharmacist's office within one week and arrange to physically pick up the signed review. The Director of Nursing or designee will fax pharmacy review to the physician's office for review and approvals of any recommendations. The Director of Nursing or designee, in partnership with the Qualified Intellectual Disabilities Professional (QIDP) will implement any approved recommendations.
The Director of Nursing or designated nurse will document all communications and file in the Individual's chart. The Director of Nursing or the designated nurse, in partnership with the QIDP will schedule all future Pharmacy 90-Days reviews for current individuals on the Microsoft Outlook calendar with calendar reminders of upcoming 90-day review.

C3
For future ICF candidates: All new admissions will be required to have their Pharmacy 90-Day Reviews within 30 days of admission. The Director of Nursing or the designated nurse in partnership with the Qualified Intellectual Disabilities Professional (QIDP) will complete the Pharmacy 90-Day Reviews within 30 days of admission. Within one week of review completion the Director of Nursing or designated nurse will faxed to the Pharmacist for review and sign off. Fax confirmations will be filed in the individual's chart. If the signed Pharmacy 90-Day Review is not returned within two weeks of it being faxed to the pharmacist office, the Director of Nursing or designated nurse will contact the pharmacist office within one week and arrange to physically pick up the signed review. The Director of Nursing or designee will fax pharmacy review to the physician's office for review and approvals of any recommendations. The Director of Nursing or designee, in partnership with the Qualified Intellectual Disabilities Professional (QIDP) will implement any approved recommendations.
The Director of Nursing or designated nurse will document all communications and file in the individual's chart. The Director of Nursing or designee will file the updated pharmacy review in the Individuals charts. The Director of Nursing or the designated nurse, in partnership with the QIDP will schedule all future Pharmacy 90-Days Reviews on the Microsoft Outlook calendar with calendar reminders of upcoming 90-day review completions.

C4:
Quarterly , the Qualified Intellectual Disabilities Professional (QIDP) will review the Individuals' charts for updated Pharmacy 90-Day Reviews and evidence of a pharmacist review and approval. The QIDP will email to the Director of Nursing or designated nurse any missing or incomplete Pharmacy 90-Day Reviews within one week of the review. Within one week of email communication, the Director of Nursing or designated nurse will correct and fax the review to the pharmacist's office for review and sign off and will file the fax confirmations in the individuals' chart. If the signed Pharmacy 90-Day review is not returned within two weeks of it being faxed to the pharmacist's office, the Director of Nursing or designated nurse will contact the pharmacist's office within one week and arrange to physically pick up the signed review. The Director of Nursing or designee will fax pharmacy review to the physician's office for review and approvals of any recommendations. The Director of Nursing or designee, in partnership with the Qualified Intellectual Disabilities Professional (QIDP) will implement any approved recommendations.

The Director of Nursing or designated nurse will document all communications and file in the individual's chart. The Director of Nursing or designated nurse will file all current pharmacy 's orders in the Individual chart.

In addition to the QIDP reviewing the charts, the Senior Director of Quality Improvement or Quality Improvement designee will also review for compliance utilizing an audit tool during their scheduled Utilization Review on 08/06/2024. The Senior Director of Quality Improvement or Quality Improvement designee will email all review finding by 08/13/2024.

C5:
The Director of Nursing is responsible for execution and tracking of activity completion for this citation. Within one week of discovery, The Director of Nursing will communicate any areas of non-compliance and follow up steps taken to the team via email, including the IDD-Division Director, Senior Director of Quality Improvement, and the Qualified Intellectual Disabilities Professional (QIDP).