Nursing Investigation Results -

Pennsylvania Department of Health
EDGEHILL NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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EDGEHILL NURSING AND REHABILITATION CENTER
Inspection Results For:

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EDGEHILL NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on March 22, 2019, it was determined that Edgehill Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirments for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.





































 Plan of Correction:


483.20(k)(1)-(3) REQUIREMENT PASARR Screening for MD & ID: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(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability.

483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with:
(i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission,
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services; or
(ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission-
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability.

483.20(k)(2) Exceptions. For purposes of this section-
(i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital.
(ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual-
(A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital,
(B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and
(C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services.

483.20(k)(3) Definition. For purposes of this section-
(i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1).
(ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in 483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter.
Observations:

Based on clinical record review and staff interview it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for one of 15 residents reviewed (Resident 56).

Findings include:

The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability.

The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level 1 PASRR determined that the person is a targeted person with mental illness or an intellectual disability. The Level II PASRR would determine if placement or continued stay in the requested or current nursing facility is appropriate.

Review of Resident R56's clinical record revealed the resident was admitted to the facility on June 21, 2018,
with a diagnosis to include delusional disorder (is a belief that is clearly false and that indicates an abnormality in the affected person's content of thought); major depressive disorder; psychosis (A mental disorder characterized by a disconnection from reality); anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).

Review of Resident 56's PASRR Level I revealed that the facility completed it on March 31, 2014, and indicated that R56 did not have a target diagnosis by not checking the yes box on page one, Section IIA-Diagnosis, despite the resident's clinical record indicated that the Resident R56 has diagnosis to include delusional disorder, major depressive disorder, psychosis, and anxiety disorder.

Interview with Employee E4, social worker, on March 21, 2019, at 9:25 a.m. confirmed the above findings.

28 Pa Code 201.8(b)(1) Management

28 Pa Code 201.8(e)(1) Management

28 Pa Code 211.5(f) Clinical records

28 Pa Code 211.10(a)(c) Resident care policies

28 Pa Code 211.16(a) Social services







 Plan of Correction - To be completed: 05/03/2019

Employee E4 was re-educated by the CED to the policy and procedure for Clinical Records/Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients and PASRR completion.
The Social Service Director or designee will complete an initial audit of completed PASRRs, to ensure that they are accurately and appropriately completed according to the resident assessment.
The Social Service Director or designee will complete a monthly audit of new admissions, to ensure appropriate completion of the PASRR.
The Social Service Director or designee will review the results of the audits during the facility's monthly QAPI meeting x three months.
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 observation, review of clinical records and staff interviews, it was determined that the facility did not follow physican orders related to medication administration for one of three residents observed (Resident R52).

Findings include:

Review of Resident R52's clinical record revealed a physician order for Vitamin D3 2000 (Vitamin supplement) one tablet daily.

Observation on March 22, 2019, at 8:50 a.m. of medication administration revealed Employee E3, LPN, did not administer the Vitamin D3 2000 one tablet daily to Resident R52 as ordered by the physician.

Interview on March 22, 2019, at 9:30 a.m. with Employee E3, LPN, where she confirmed she did not administer the Vitamin D3 2000 one tablet daily to Resident R52 as ordered by the physician.

The facility did not follow physican orders related to medication administration


28 Pa Code: 211.5(f) Clinical records.

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













 Plan of Correction - To be completed: 05/03/2019

Employee E4 was re-educated by the CNE to the policy and procedure for medication administration which includes following physician orders. Employee E4 successfully completed the medication administration competency.
The facility licensed nursing staff have been re-educated to the policy and procedure medication administration by the CNE. CNE or designee will oversee medication pass utilizing the medication administration competency, which includes physician orders.
The CNE or designee will complete Medication Administration Competencies with four nurses monthly in order to capture all nurses each quarter thereafter.
The CNE or designee will review the results of the audits at the facility's monthly Quality Improvement Meeting x three months.


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