|§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.
Based on a review of the Facility Assessment, the facility failed to assess the knowledge, skills, abilities, behaviors and other characteristics needed to ensure that the agency staff were able to perform work roles to meet the residents' needs during both day-to-day operations and emergencies. This failure resulted in an immediate jeopardy situation when the facility failed to ensure a safe environment was maintained regarding fire drills related to a lack of fire safety training for agency nursing staff, and the facility failed to ensure that agency nursing staff received mandatory inservice education and evaluations for competency in nursing skill sets.
Review of the Facility Assessment tool, updated January 30, 2019, revealed the facility would determine what resources were necessary to provide competent care for the typical resident population, including staff and staff training/education and competencies. The Facility Assessment further specified the service and care offered based on the identified residents needs and identified the facility resources needed to provide competent support and care to the resident population every day and during emergencies.
Further review of the facility assessment revealed no information was provided related to the types of staff education, training or competencies required by agency personnel to provide the appropriate level of care to their resident population. No information was provided regarding required in-service training to the agency personnel including fire safety, person-centered care, nursing skills, management of medical conditions, and mental health and behaviors, as required.
Based on the findings of the survey completed on March 8, 2019, which identified multiple areas of regulatory non-compliance, including an Immediate Jeopardy situation and harm level deficiency, it was determined the Nursing Home Administrator and the Director of Nursing failed to conduct, document and maintain a facility assessment which identified the proper use of agency personnel and resources necessary to competently and safely care for the residents of the facility during both day-to-day operations and emergencies.
28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/25/18, 05/07/18, 03/01/17
28 Pa. Code 201.18(a) Management
28 Pa. Code 201.18(b)(1) Management
Previously cited 05/07/18, 03/01/17
28 Pa. Code 201.18(b)(3)(e)(1) Management
Previously cited 05/07/08
28 Pa. Code 211.12(c) Nursing services
Previously cited 05/07/18
| ||Plan of Correction - To be completed: 04/12/2019|
1.There were no residents effected as a result of this practice.
2.The facility will ensure thru self assessment and education that agency nursing staff have the appropriate knowledge, competency, and skill sets in fire safety, person centered care, nursing skills, management of medical conditions, and mental health and behaviors.
3.Nurse educator or designee will educate nursing agency staff on the appropriate knowledge, competency, and skill sets in fire safety, person centered care, nursing skills, management of medical conditions, and mental health and behaviors.
4.Audits will be performed by Unit Manager or designee 3x/wk for 4 weeks then weekly for 2 months.
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended