Nursing Investigation Results -

Pennsylvania Department of Health
ROSE CITY NURSING AND REHAB AT LANCASTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ROSE CITY NURSING AND REHAB AT LANCASTER
Inspection Results For:

There are  177 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.
ROSE CITY NURSING AND REHAB AT LANCASTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on an abbreviated survey completed on February 28, 2019 in response to two complaints at Rose City Nursing and Rehab at Lancaster, it was determined that Rose City Nursing and Rehab at Lancaster 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:


483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements: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.
483.15(c) Transfer and discharge-
483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i) Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with 483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.
Observations:

Based on a review of clinical record, and staff interview, it was determined that the facility failed to development a discharge care plan for one of three residents reviewed (Resident R1).

Findings include:

Review of Resident R1's diagnoses list included the diagnosis of Parkinson's disease (progressive disease of the central nervous system), dementia (progressive degenerative disease of the brain) without behavioral disturbances, abnormalities of gait, dysphagia (difficulty swallowing), Diabetes Mellitus (failure of the body to produce insulin) and bipolar disorder (condition in which a person has period of depression and periods of being extremely happy).

Review of Resident R1's annual Minimum Data Set assessment (MDS assessment of resident care needs) completed on November 23, 2018, revealed a BIMS (Brief Interview of Mental Status) score of 13 out of 15 which identified the resident as cognitively intact.

Review of Resident R1's social service note dated November 8, 2018, revealed that a discharge meeting was held with the resident and family to discuss discharge plans. It was explained to the resident's responsible party that due to the resident's sexual assault actions towards a female resident the resident would be endangering the safety of the other residents. The resident's responsible party was informed that a 30 day notice was presented to the resident. Further review of the social services note indicated "MD will not agree on signing an order to transition to other facilities to include ALF (assisted living facility, Skilled Nursing facilities). Responsible party/resident were told that 11/26/18 will be his last day in the facility. The resident/responsible party stated that the resident might as well go to a local shelter due to not accepting the resident in the home. "Both responsible party and resident stated understanding the situation and will be accepting to go to the shelter."

Review of the resident's clinical record confirmed that the resident was presented with a "Notice of intent to discharge" on October 26, 2018.

Review of nursing note dated November 23, 2018 revealed that the interdisciplinary staff met with the family to discuss the resident's upcoming discharge. The resident's family was made aware that the pending discharge to the local shelter had been cancelled at the request of the shelter. The note further stated, "Facility will continue to work toward finding a discharge location conducive to the resident's needs."

Review of the resident's care plan last revised January 31, 2019 revealed that no discharge care plan was developed once the resident was presented with a 30 days discharged notice on October 26, 2018. Further there was no discharge care plan developed after Resident R1's 30 days noticed expired on November 26, 2018 and the facility continue efforts for an alternate placement.

Interview conducted with Social Services, Employee E3, on February 13, 2019, at 12:57 p.m. revealed that on November 21, 2018, the resident was denied admission to the local shelter due to the sexual behaviors exhibited by the resident. Employee E3 further confirmed that there was no care plan and interventions developed for Resident R1 to be discharge from the facility within 30 days.

The facility failed to developed a discharge care plan for Resident R1.

28 Pa Code 211.11(b) Resident care plan

28 Pa Code 211.12(d)(1)(5) Nursing services
























 Plan of Correction - To be completed: 03/26/2019

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable states and federal regulatory requirements.
1) Resident 1 has been discharged from the facility.

2) A review of current residents will be completed to ensure they have an updated discharge plan of care in place.

3) Education will be provided to the Social Services Director on the completion of discharge plans of care for each resident.

4) NHA/Designee will conduct an audit of 10 residents weekly for two months to ensure that each resident has an updated discharge plan of care. Results of audits will be reviewed in facility QAPI meeting for further action planning.
483.25 REQUIREMENT Quality of Care: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.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of clinical record, it was determined that the facilty failed to ensure that medications and treatments were administered as order by the physician for one of three clincal records reviewed. (Resident R1)

Findings include:

Review of Resident R1's electronic clinical record revealed the diagnoses of Diabetes Mellitus (failure of the body to produce insulin), Parkinson's Disease (progressive disease of the central nervous system), Dementia (progressive degenerative disease of the brain), Hyperlipidemia (high cholesterol), Bipolar disorder (condition in which a person has period of depression and periods of being extremely happy), Hypertension (high blood pressure), Constipation, Insomnia, Abnormalities of gait.

Review of Resident R1's January 2019 medication administration record revealed no documented evidence that the following medications were adminsitered at 9:00 p.m. on January 8, 2018 as ordered by the physician: Aripiprazole (antipsychotic medication) tablet 25 milligrams (mg) by mouth at bed time; Depakote (mood stabilizer) 250 mg one tablet by mouth at bedtime; Donepezil (medication used to treat confusion related to Alzheimer's disease) 10 mg at bedtime; Levemir (insulin medication) FlexPen solution 100 unit inject 10 unit subcutaneously at bedtime; Melatonin (sleep induce medication) 3 mg by mouth at bedtime; Simvastatin (medication use for the treatment of high cholesterol) 10 mg by mouth at bed time; Carvedilol (blood pressure medication) 3.125 mg by mouth two times a day hold to hear rate under 60 and or systolic blood pressure less than 100; Accu checks (blood sugar checks) before meals and at bed time, Carbidopa-Levodopa (medication for the treatment of Parkinson's disease) 25-250 mg one tablet by mouth four times a day.

Further review of the January 2019 medication administration record revealed no documented evidence that the following medications were adminsitered at 5:00 p.m. on Janaury 8, 2018 as ordered by the physician: Benztrophine Mesylate (medication use for the management of Parkinson's disease) 0.5mg by mouth two time a day; Depakote (mood stabilizer) delayed release 500 mg one tablet by mouth tow times a day; Gabatepentine (used with other medications to prevent and control seizures) 100 mg one capsule by mouth two times a day, Metformin (medication use for the treatment of diabetes) 1000 mg by mouth two times a day; Senna Tablet (medication for the treatment of constipation) 8.6 mg two tablets by mouth two times a day;

Review of Resident R1's treatment administration record revealed no documented evidence that on November 11, 2019 and November 13, 2019 the resident received the following treatment as ordered by the physcian: left 1st, 2nd and 3rd toes, wash with soap and water, scrubbing gently, rinse well and pat dry, apply Silvadene (topical antibiotic)to wound, cover with alginate, wrap with kling going around the foot and over toes to produce padding to wound when wearing shoes.

The facility failed to ensure the Resident R1 received medications and treatments as ordered by the physician.

28 Pa Code 211.10(c) Resident care policies

28 Pa Code 211.12(d)(1)(5) Nursing services






 Plan of Correction - To be completed: 03/26/2019

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable states and federal regulatory requirements

1) Resident 1 has been discharged from the facility.

2) A review of all current residents will be conducted by DON/Designee to ensure that residents are receiving medications and treatments as ordered by Physician.

3) Licensed nurses will administer and document medications and treatments as ordered by the Physician.

4) ADON/Designee will conduct an audit for 15 residents weekly for two months to ensure that each resident is receiving medications and treatments as ordered by Physician. Results of audit will be reviewed in facility QAPI meeting for further action planning.
483.40(b)(1) REQUIREMENT Treatment/Srvcs Mental/Psychoscial Concerns: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.
483.40(b) Based on the comprehensive assessment of a resident, the facility must ensure that-
483.40(b)(1)
A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being;
Observations:

Based on clinical record review and staff interview, it was determined that he facilty failed to ensure timely delivery of psychiatric services for one of three residents reviewed.(Resident R2)

Findings included:

Review of Resident R2's electronic clinical record revealed the diagnoses of major depressive disorder (major loss of interest in pleasurable activities), anxiety disorder and bipolar disorder (condition in which a person has period of depression and periods of being extremely happy).

Review of physician's progress notes dated November 5, 2018 noted the resident continued with agitation "over the weekend the patient struck several residents following no provocation. The plan of care noted by the physician included "The patient continues with agitation. He's already in large doses of these Latuda (antipsychotic medication) and Seroquel (antipsychotic medication). He has as needed Seroquel and Haldol gel (antipsychotic medication). He is on Depakote. I will increase his Depakote form 625 mg twice a day up to 500 mg three times a day. We'll see if we can get some improvement in his behaviors."

Review of nursing documentation dated November 30, 2018 revealed that the resident went to an appointment at a outpatient psychiatric agency. The resident received all the medication before leaving the facility. The facility received a call from the physician at the outpatient psychiatric agency stating that the physician could not evaluate the resident due to his level of sedation, he was unable to wake him up to ask him question. The note further stated "He stated that it was recommended that the resident was taken to the Emergency Room to be assessed. This nurse stated that when resident tis not medicated, he is extremely combative, scaring other residents by pacing the hallway aggressively screaming in Spanish, resistive and combative with care. The dr then stated that if that is the resident's baseline, them threshold not be seen an outpatient setting and exposed ot other patients at that facilty, but should be followed by an in house psych Dr."

Review of the outpatient psychiatric consultation report dated November 30, 2018 confirmed that the psychiatrist was "unable to diagnosed or evaluate [the resident] at this time." The recommendations was: "Pt should get medical clearance first...Recommend to go to ER (Emergency Room) for medical clearance first.

Review of nursing note dated November 30, 2018 at 12:29 p.m. confirmed that the resident's primary physician was contacted with the findings from the outpatient psychiatric agency and the physician "approved of an order to send resident to ER for evaluation."

Review of Resident R2's entire clinical record revealed no documented evidence that the resident was transferred to the hospital for evaluation and/or discontinuation of the order by the physician to send the resident to the hospital.


Review of Resident R2's physcian's orders revealed that an order for a psychiatric evaluation was not obtained until December 3, 2018 four days after the resident was seen at the outpatient psychiatric agency.

Review of Resident R2's physican's progress notes revealed that the resident was not evaluate by the psychiatrist's Certified Nurse Practitioner until December 13, 2018.

Interview conducted with the Director of Nursing on February 19, 2019 at 3:23 p.m. revealed that once the resident returned to the facility he was found to no longer to be lethargic and "in house psychiatric" was then pursued. The order was not obtained until December 3, 2018 because it was the weekend.

The facility failed to ensure that Resident R2 received timely psychiatric services.

28 Pa Code 211.10(c) Resident care policies

28 Pa Code 211.12(d)(1)(5) Nursing services






 Plan of Correction - To be completed: 03/26/2019

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable states and federal regulatory requirements

1) Resident 2 is receiving psychiatric services.

2) A review of current residents will be completed by the ADON/Designee to ensure timely delivery of psychiatric services.

3) Outpatient psychiatric consultations will be reviewed daily to ensure timely implementation of psychiatric services.

4) ADON/Designee will conduct an audit of residents who are currently going to outside psych appointments to ensure recommendations to in-house psych are being followed in timely manner weekly for two months.
483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:
Based on clinical record review, it was determined that the facility failed to accurately identify specific target behaviors for the each psychotropic medications ordered by the physician for two of three residents reviewed (Resident R1 and Resident R2).

Findings include:

Review of Resident R1's electronic clinical record revealed the diagnoses of bipolar disorder (condition in which a person has period of depression and periods of being extremely happy).

Review of January 2019 Medication Administration Record (MAR) revealed that the resident was order Aripiprazole (antipsychotic medication) 25 milligrams (mg) at bedtime for bipolar disorder and Depakote (mood stabilizer medication) delayed release 250 mg at bedtime for mood/aggression related to bipolar disorder.

Review of Resident R1 Janaury Treatment Administration Record (TAR) revealed behavior monitoring documentation for mood changes insomnia.

Additional review of Resident R2's January 2019 TAR failed to indicate which targeted behaviors was for each of the medications listed above.

Review of Resident R2's electronic clinical record revealed the diagnoses of major depressive disorder (major loss of interest in pleasurable activities), anxiety disorder and bipolar disorder (condition in which a person has period of depression and periods of being extremely happy).

Review of January 2019 Medication Administration Record (MAR) revealed that the resident was ordered Seroquel (antipsychotic medication) 100 milligrams (mg) by mouth two times a day for psychosis; Depakote Sprinkles (mood stabilizer) 500 mg three times a day fir bipolar disorder; Haldol Gel (antipsychotic medication) .25 mg topically three times for agitation; Haldol gel .25 mg every 8 hours as needed for agitation and Seroquel 25 mg every 6 hours as needed for agitation.

Further review of the Janaury 2019 MAR revealed behavior monitoring documentation for continuous screaming/yelling, striking, and uncooperative.

Additional review of Resident R2's January 2019 MAR failed to indicate which targeted behaviors was for each of the medications listed above.


28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.5(h) Clinical records

28 Pa. Code 211.12 (d)(1)(5) Nursing services

28 Pa. Code 211.12(d)(3) Nursing services



 Plan of Correction - To be completed: 03/26/2019

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable states and federal regulatory requirements

1) Resident 1 has been discharged from the facility. Resident 2 has target behaviors identified for each psychotropic medication ordered by physician.

2) A review of current residents receiving psychotropic medication will be completed by DON/Designee to ensure that targeted behaviors are identified for each of their psychotropic medications.

3) Licensed nursing staff will ensure target behaviors are identified when new psychotropic medications are ordered by the physician.

4) DON/Designee will conduct an audit of 15 residents weekly for two months to ensure that each resident targeted behaviors are identified for their psychotropic medications. Will continue to review findings in QAPI meeting for further action planning.
483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:
Based on a review of clinical record, staff interview and review of facility policy, it was determined that the facility failed to ensure that clinical records were complete for one of three residents reviewed (Resident R1).

Findings include:

Review of the facility policy title "Transfer and Discharge Notice" revised June 23, 2017 revealed "when a resident is transferred, a summary of treatment given at the nursing home, condition of the resident at time of transfer and date and place to which he/she is transferred shall be entered in the record. If the transfer is due to an emergency, this information will be record in the resident's record."

Review of Resident R1's diagnoses list included the diagnosis of Parkinson's disease (progressive disease of the central nervous system), dementia (progressive degenerative disease of the brain) without behavioral disturbances, abnormalities of gait, dysphagia (difficulty swallowing), Diabetes Mellitus (failure of the body to produce insulin) and bipolar disorder (condition in which a person has period of depression and periods of being extremely happy).

Review of a progress note dated January 17, 2019, at 1:15 p.m. completed by the Nursing Home Administrator noted "met with resident to discuss his discharge this afternoon...Resident is in agreement with the discharge and location, he expressed his eagerness to be leaving the facility. A voice message has been left for the son regarding the discharge time and destination." Review of the next available note on January 17, 2019 at 3:37 p.m. (approximately 2 hours since the last note) revealed that the Nursing Home Administrator documented "It was explained to resident that his MD (physician) would not provide a discharge order. Resident expressed that he still wanted to be discharged. Education was provided to resident regarding the risks of signing out AMA (against medial advised). Resident voiced that he understood and signed the AMA paperwork. The resident was made aware that upon leaving the facility the following will be provided to him: medications, a list of his current medications, a copy of his care plan, his face sheet and the information regarding his scheduled PCP (primary care physician) appointment in the community. Resident voice that he understood."

Review of the discharged note dated January 17, 2019, at 5:51 p.m. revealed that the resident left the facility at 5:15 p.m. via the facility transportation service. "He was released with his remaining cycle of medications... Additional education was sent with resident pertaining to each of his medications."

Interview with the Social Service, Employee E3, on February 13, 2019, at 12:30 p.m. confirmed that there was no documentation of the location where Resident R1 was discharged to. Employee E3 indicated that Resident R1 was discharged to a men shelter in another county.

28 Pa Code 211.5(f) Clinical records






 Plan of Correction - To be completed: 03/26/2019

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable states and federal regulatory requirements

1) Resident 1 has been discharged from the facility.

2) A review will be completed of residents that discharged from the facility within the last 30 days to ensure their clinical records are complete and includes the location of discharge.

3) Education will be provided to the Social worker/designee on ensuring complete clinical records upon discharge to include the location of the discharge.

4) NHA/Designee will conduct an audit of residents discharging weekly for two weeks to ensure residents clinical records are complete and include discharge location. Will review findings in QAPI meeting for further action planning.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port