Nursing Investigation Results -

Pennsylvania Department of Health
ALLIED SERVICES TRANSITIONAL REHABILITATION UNIT
Patient Care Inspection Results

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ALLIED SERVICES TRANSITIONAL REHABILITATION UNIT
Inspection Results For:

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ALLIED SERVICES TRANSITIONAL REHABILITATION UNIT - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare Recertification, State Licensure and Civil Rights Compliance Survey completed on February 22, 2019, it was determined that the Allied Services Transitional Rehab Unit was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on review of narcotic shift count records and staff interview, it was determined that the facility failed to implement procedures to promote accurate narcotic medication records on one of seven medication carts.

Finding include:

A review of the facility's policy entitled "Administration of Medication Schedule II-V Control Drugs" reviewed by the facility June 1, 2018, revealed that at each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and documented on the aforementioned form.

A review of the "Narcotic Record" form for the East Hall and West Hall medication carts on February 21, 2019, at approximately 8:11 a.m., revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during multiple shifts on the following dates to verify counts of controlled drugs in the respective medication carts: February 4, 5, 8, 10, 11, 12, and 18, 2019.

Interview with the registered nurse consultant on February 22, 2019, at approximately 9:07 a.m. confirmed that there were no nursing staff signatures on the dates noted above to demonstrate consistent implementation of facility procedures for promoting accurate drug records.

28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services.
Previously cited 3/9/18

28 Pa Code 211.9(a)(1)(k)Pharmacy services.


















 Plan of Correction - To be completed: 04/16/2019

1. An audit will be completed on the East Hall and the West Hall narcotic records to ensure that nursing staff is consistently implementing procedures to promote accurate narcotic drug reconciliation per facility policy.

2. Licensed nursing staff will be in-serviced on the facility policy "Administration of Medication Schedule II-V Control Drugs."

3. The Don, or designee, will perform daily audits on the East Hall and West Hall narcotic records to ensure that nursing staff is consistently implementing procedures to promote accurate narcotic drug reconciliation per facility policy.

4. Results of these audits will be reviewed monthly for two months, reported to the QA committee, and then re-evaluated.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on observation, staff interview and review of facility policy, it was determined that the facility failed to implement procedures to effectively clean and disinfect glucose meters (a medical device for determining the approximate concentration of glucose \ in the blood) in a manner to prevent the potential spread of infection.

Findings include:

Review of the facility policy entitled "Nova Stat Strip Glucose Monitor" last reviewed by the facility June 1, 2018, revealed that the aforementioned glucose monitor must be cleaned between each resident use with a bleach germicidal (an antiseptic wipe that destroys harmful microorganisms) wipe. Procedures include wiping the external surface of the meter using a fresh germicidal wipe. The surface of the meter should be thoroughly wiped at a minimum of three times both horizontally and vertically. Further review of the policy, indicated that staff should ensure the meter surface stays wet for one minute and then allowed to air dry for an additional minute. This type of meter was the meter the facility utilized for each resident requiring blood glucose testing.

Observation of a medication administration pass on February 21, 2019, at approximately 7:41 a.m. revealed that Employee 1 (LPN) obtained Resident 179's blood using a glucose meter (Nova Stat Strip Glucose Monitor) to determine the resident's blood glucose level. After documenting the amount of glucose on the medication administration record, Employee 1 proceeded to clean the meter using an alcohol wipe (70% alcohol), not a germicidal wipe.

Interview with Employee 1 at approximately 8:15 a.m. confirmed that she used alcohol wipes, not germicidal wipes.

During an interview on February 22, 2019, at approximately 9:19 a.m. the registered nurse consultant confirmed that alcohol wipes are not effective against viral bloodborne pathogens and that staff failed to follow facility policy regarding the use of germicidal wipes.


28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services.
Previously cited 3/9/18

28 Pa. Code 211.10 (a)(d) Resident care policies.




















 Plan of Correction - To be completed: 04/16/2019

1. Employee 1 has been educated on the facility policy for cleaning the Nova Stat Strip Glucose Monitor. Germicidal wipes will be kept on the medication carts with the glucose monitors.

2. An audit will be completed on each shift to ensure that nursing staff is consistently implementing procedures to effectively clean and disinfect the Nova Stat Strip Glucose Monitor per facility policy.

3. Licensed nursing staff will be in-serviced on the facility policy "Nova Stat Strip Glucose Monitor."

4. The DON, or designee, will perform daily audits on each shift to ensure that nursing staff is consistently implementing procedures to effectively clean and disinfect glucose meters in a manner to prevent the potential spread of infection. Results of these audits will be reviewed monthly for two months, reported to the QA committee, and then re-evaluated.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on a tour of the food and nutrition services department, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for microbial growth in food, which increased the risk of food-borne illness.

Findings include:

During the initial tour of the food and nutrition services department on February 20, 2019, at approximately 8:19 a.m. accompanied by the certified dietary manager (CDM), the following sanitation issues, with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified:

A dust build-up was observed in the vents on the wall-mounted air conditioner.

An accumulation of dust was observed on top of the two convection ovens, the steamer, the coffee machine and on the ledge above the dish machine.

The lid on the rice container (bulk) located near the deep fat fryer was observed covered with grease and dust.

The inside of the tray cart was observed to be soiled with dust and dried food.

Food debris was observe on the gaskets on the doors of the reach-in refrigerator and freezer; one gasket was ripped.

A heavy grease and dust build-up was observed on the ceiling vent located in the dish machine room.

Interview with the CDM at this time, confirmed the above observed food safety and sanitation concerns.

28 Pa. Code 211.6(c)(d) Dietary services.

28 Pa. Code 207.2(a) Administrator's responsibility.



















































 Plan of Correction - To be completed: 04/16/2019

1. The dust build-up in the vents of the wall-mounted air conditioner has been cleaned along with the top of the two convection ovens, the steamer, coffee machine and on the ledge above the dish machine. The bulk rice container and lid have been replaced with a new container. The inside of the tray cart has been cleaned. The reach-in refrigerator has been cleaned and the ripped gasket was repaired. The ceiling vent in the dish machine room has been cleaned.

2. An audit will be completed to ensure that acceptable practices for the storage and service of food are maintained to prevent the potential for microbial growth in food.

3. Dietary staff will be re-educated to maintain acceptable practices for the storage and service of food.

4. Audits will be completed daily by Administrator, or designee, to ensure that acceptable practices are maintained for the storage and service of food to prevent the potential for microbial growth in food. Results of these audits will be reviewed monthly for two months, reported to the QA Committee, and then re-evaluated.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan: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.
483.21 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:

Based on clinical record and select policy review and staff and resident interview, it was determined the facility failed to include, in the resident's baseline plan of care, minimum standards of care required for one resident out of one resident on transmission based precautions (Resident 172).

Findings include:

A review of the clinical record of Resident 172 revealed admission to the facility on February 16, 2019, for aftercare following joint replacement. The resident was admitted to the facility on isolation precautions for Multi Drug Resistant Organisms (MDRO's) MRSA of the nares.

A review of the resident's initial (baseline) plan of care failed to indicate that the resident was on isolation (contact) precautions.

The facility policy entitled Infection Control Policy and Procedure dated June 2014 indicated the application of contact precautions for patients infected or colonized with MDRO's. According to the policy, all departments who may come in contact with the resident will be notified, nursing will place a please see nurse magnet on the door frame. Patients on contact precautions according to this policy require either a private room or cohorting, dedicated disposable equipment, healthcare workers should wear gloves, encourage patients to wash hands frequently and visitors should clean hands when they enter and leave the room.

Interview with the Director of Nursing on February 22, 2019, confirmed that the facility failed to indicate on the baseline care plan that the resident was on contact precautions.


28 Pa. Code 211.11(c)(d) Resident care plan
Previously cited 3/9/18



 Plan of Correction - To be completed: 04/16/2019

1. Resident 172 has been discharged to the community.

2. An audit will be completed by DON, or designee, on residents on isolation precautions to ensure that a baseline plan of care is completed to properly care for the resident.

3. Licensed nursing staff will be in-serviced on appropriate development and implementation of baseline care plans, to indicate minimum standards of care required for a resident on transmission based precautions.

4. The DON, or designee, will audit admissions daily to ensure that each resident's baseline care plan has been properly developed. Results of these audits will be reviewed monthly for two months, reported to the QA committee, and then re-evaluated.


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