Nursing Investigation Results -

Pennsylvania Department of Health
SPIRITRUST LUTHERAN THE VILLAGE AT SPRENKLE DRIVE
Patient Care Inspection Results

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SPIRITRUST LUTHERAN THE VILLAGE AT SPRENKLE DRIVE
Inspection Results For:

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SPIRITRUST LUTHERAN THE VILLAGE AT SPRENKLE DRIVE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Findings of an abbreviated incident survey completed on April 16, 2019, at Spiritrust Lutheran The Village at Sprenkle Drive identified that the facility was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(b) The facility must develop and implement written policies and procedures that:

483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

483.12(b)(3) Include training as required at paragraph 483.95,
Observations:


Based on policy, interview and record review, it was determined that the facility failed to carry out verification screening for a valid registry status of (The Nurse Aide Registry lists nursing assistants who have met Pennsylvania training and/or testing standards to work in nursing homes. The registry also has information about nursing assistants who have substantiated findings of abuse, neglect and misappropriation) for one of two Nurse Aides, (Nurse Aide 1).

Findings include:

Review of the facility policy titled, Abuse/Neglect Exploitation Prevention Standard for Skilled Care, last revised October 4, 2017, states that the facility will screen employees by checking with the appropriate Nurse Aide Registry.

A review of NA 1's employee record on April 16, 2019, revealed that the registry status expired March 31, 2019.

Further review of the NA 1's schedule, for worked hours, revealed that NA 1 continued to provide care to residents with an expired registry status on the following dates: April 1, 2019, April 2, 2019, April 3, 2019, April 4, 2019, April 7, 2019, and April 8, 2019.

During an interview with the Director of Nursing on April 16, 2019, at approximately 4:00 PM she revealed that she checks the Registry status monthly but this NA's expiration status was realized after the expiration date.

During an interview with the Nursing Home Administrator on April 16, 2019, he confirmed that he was aware that all NA's registry status must remain valid, while employed.

28 Pa. Code 201.18(e)(1) Management









 Plan of Correction - To be completed: 05/07/2019

1.) NA 1 was suspended when incident was identified on April 9, 2019 and reinstated when certification was renewed on April 11, 2019.
2.) Full house audit was completed for all nursing staff to ensure registry statuses are valid.
3.) Nursing Home Administrator will educate the Director of Nursing and Assistant Directors of Nursing on the facility's Abuse/Neglect Exploitation Prevention Standard. Tracking has been implemented and will be placed in the care hubs to notify nursing of the upcoming renewals necessary to remain active in the nursing registry.
4.) The Director of Nursing/designee will audit biweekly x2 then monthly x2 to ensure all nurses remain active in the nursing registry. Audits will be reviewed at QAPI meeting for follow up and additional recommendations.
201.19 LICENSURE Personnel policies and procedures.:State only Deficiency.
Personnel records shall be kept current and available for each employe and contain sufficient information to support placement in the position to which assigned.
Observations:


Based on record review and interview it was determined that the facility failed to ensure a valid Nurse Aide registry status of (The Nurse Aide Registry lists nursing assistants who have met Pennsylvania training and/or testing standards to work in nursing homes. The registry also has information about nursing assistants who have substantiated findings of abuse, neglect, and misappropriation) for one of two Nurse Aides reviewed, (Nurse Aide 1).

Findings include:

According to state regulation 28 Pa. Code 201.19 a Nurse Aide is an individual providing nursing care or nursing related services to residents in a facility and who appears on the Commonwealth Nurse Aide Registry.

A review of NA 1's employee record on April 16, 2019, revealed that NA 1's registry status expired March 31, 2019.

Further review of the NA's schedule, for worked hours, revealed that she continued to provide care to residents with an expired registry status on the following dates: April 1, 2019, April 2, 2019, April 3, 2019, April 4, 2019, April 7, 2019, and April 8, 2019.

During an interview with the Director of Nursing on April 16, 2019, at approximately 4:00 PM she revealed that she checks the Registry status monthly but this NA's expiration status was realized after the expiration date.

During an interview with the Nursing Home Administrator on April 16, 2019, he confirmed that he was aware that all NA's registry status must remain valid, while employed.












 Plan of Correction - To be completed: 05/07/2019

1.) NA 1 was suspended when incident was identified on April 9, 2019 and reinstated when certification was renewed on April 11, 2019.
2.) Full house audit was completed for all nursing staff to ensure registry statuses are valid.
3.) Nursing Home Administrator will educate the Director of Nursing and Assistant Directors of Nursing on the facility's Abuse/Neglect Exploitation Prevention Standard. Tracking has been implemented and will be placed in the care hubs to notify nursing of the upcoming renewals necessary to remain active in the nursing registry.
4.) The Director of Nursing/designee will audit biweekly x2 then monthly x2 to ensure all nurses remain active in the nursing registry. Audits will be reviewed at QAPI meeting for follow up and additional recommendations.

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