§483.70(e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include:
§483.70(e)(1) The facility's resident population, including, but not limited to, (i) Both the number of residents and the facility's resident capacity; (ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; (iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population; (iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and (v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.
§483.70(e)(2) The facility's resources, including but not limited to, (i) All buildings and/or other physical structures and vehicles; (ii) Equipment (medical and non- medical); (iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies; (iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; (v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and (vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.
§483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.
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Observations:
Based on staff interviews and a review of the facility's assessment and resident census and condition it was determined that the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for its specific resident population.
Findings include:
Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include:
The facility's resident population, including, but not limited to, (i) Both the number of residents and the facility's resident capacity; (ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; (iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population;
Review of the Facility Assessment dated December 2023, indicated the following: The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population.
Diseases/Conditions & Physical/Cognitive Disabilities for Which We Provide Care: failed to include smoking residents, polysubstance abuse, drug abuse, alcohol abuse, and negative pressure wound therapy (wound vac).
Interview on 3/4/24, at 10:22 a.m. the Director of nursing confirmed the facility failed to implement its Facility Assessment as described above to care for its specific resident population. 28 Pa Code 201.14(a) Responsibility of licensee.
28 Pa Code 201.18(a)(b)(1)(e)(1) Management.
| | Plan of Correction - To be completed: 05/01/2024
0838 1. Although the skilled nursing facility is not a substance abuse center, the NHA reviewed the facility assessment and updated it to include "Smoking" and Wound vacuums" as well as to assist residents as practicable as possible in the event they actively require support for "poly-substance abuse," "drug use," "alcohol abuse." 2. The Director of Nurses and Assistant Administrator were re in-serviced by the NHA on ensuring the facility assessment is up to date and includes and addresses the resident population to ensure the facility assessment identifies specific resources utilized by the facility to properly care for the resident population. 3. The NHA will audit the facility assessment quarterly to ensure the facility assessment is up to date and includes and addresses the resident population to ensure the facility assessment identifies specific resources utilized by the facility to properly care for the resident population. Audit findings will be shared with QAPI committee.
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