Nursing Investigation Results -

Pennsylvania Department of Health
HOMELAND CENTER
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
HOMELAND CENTER
Inspection Results For:

There are  47 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.
HOMELAND CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid, State Licensure, Civil Rights survey and an Abbreviated complaint survey completed on April 4, 2019, it was determined that Homeland Center 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:


483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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.
483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:


Based on review of select facility documents and staff interviews it was determined that the facility failed to ensure each resident is informed of charges and services not covered under Medicare A for two of three residents reviewed (Residents 43 and 58).

Findings Include:

Review of Resident 43's Skilled Nursing Facility Beneficiary Protection Notice form revealed a last covered day of Medicare Part A skilled services of January 25, 2019.

Further review of Resident 43's Beneficiary Protection Notice form revealed he was not provided the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage form (SNFABN) to notify him of the estimated cost of continued services provided by the facility not covered by the Medicare A benefit.

Review of Resident 58's Skilled Nursing Facility Beneficiary Protection Notice form revealed a last covered day of Medicare Part A skilled services of January 11, 2019.

Further review of Resident 58's Beneficiary Protection Notice form revealed she was not provided the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage form (SNFABN) to notify her of the estimated cost of continued services provided by the facility not covered by the Medicare A benefit.

An interview with Registered Nurse Assessment Coordinator (RNAC) on April 2, 2019, at approximately 10:00 AM revealed that ABN's had not been completed as she was not aware they needed to be done.

During an interview with the Nursing Home Administrator (NHA) on April 4, 2019, at 1:28 PM the NHA revealed the expectation that the SNF/ABN forms should have been completed.

28 Pa. Code 201.18 (a) Management

28 Pa. Code 201.29 Resident rights











 Plan of Correction - To be completed: 04/22/2019

Preparation and submission of this Plan of Correction is required by state and federal law. This plan does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding.
Homeland Center appreciates the efforts of the state survey team to serve the best interest of Homeland Center Residents.
RNAC will explain to Resident 43 and Resident 58, and/or Responsible Party, situation whereas SNFABN form was not provided and apologize for such.
Procedure for completion and presentation of SNFABN form for current and future Resident's, including Resident 43 and Resident 58, reviewed and modified to ensure current and future compliance for Residents continuing to live in facility. RNAC responsible to initiate timely completion of SNFABN form, obtaining current information, as needed, from Finance office.
Quality Assurance Performance Improvement (QAPI), Performance Improvement Plan, will be created. This will include Administrative Assistant for QAPI Coordination reviewing all Resident's where Medicare A coverage concluded to ensure reaction for timely compliance. This includes discontinuance of therapy services, discontinuance due to election of Hospice benefit, and discontinuance associated to change in skilled nursing benefit.
Results of QAPI Performance Improvement Plan will be presented at the weekly Clinical/QAPI meeting. Further interventions will occur if determined 100% timely accuracy is not being achieved. Administrator will receive results of QAPI Performance Improvement Plan at weekly Clinical/QAPI meeting.
Administrator, RNAC, Administrative Assistant responsible for QAPI, Director of Finance, and Director of Rehab will be responsible for on-going, consistent compliance.

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed: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(c) Menus and nutritional adequacy.
Menus must-

483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

483.60(c)(2) Be prepared in advance;

483.60(c)(3) Be followed;

483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

483.60(c)(5) Be updated periodically;

483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.
Observations:


Based on observations, review of select facility documents and staff interviews it was determined that the facility failed to follow the scheduled menu as per the advance prepared menu for two out of two separate trayline observations reviewed regarding food portions.

Findings include:

Observation was made in the facility main kitchen on April 1, 2019, of the lunch meal tray line at 11:55 AM which revealed what appeared to be a too small portion of one slice turkey loaf being served. Additional observation were made which revealed that the portion of shepherd's pie being served was inconsistent. An observation was made that residents' receiving their meal on a plate received one overloaded scoop plus a second almost full scoop. It was observed that for some residents the shepherd's pie was served into purple bowls. Portions served into the purple bows started out with one non-overloaded scoop of shepherds' pie followed with what appeared to be one quarter of a scoop. The last several bowls were served one non-overloaded scoop and almost nothing in a second scoop attempt. It was determined that the last cart of meals on trays were for residents living in the Dementia unit.

During an interview with Dietary Server (DS) 1 at 12:10 PM following end of this lunch service, DS 1 was asked what the portion size was for the shepherds' pie. DS 1 stated that it was "four ounces." DS 1 also showed surveyor that she was using a four ounce scoop. Dietary Supervisor (DS) 2 who was on-site at the end of this tray service on April 1, 2019, was asked to weigh a portion of the turkey loaf which had appeared to be small. In consultation with Purchasing Supervisor (PS 1), DS 2 determined that they did not have a food scale on sight to weight the turkey loaf. One slice of turkey loaf was then wrapped to be weighed the following day.

Review of Dietary Services' Diet Spreadsheet for all diets revealed that the set portion for the turkey loaf to be served at lunch on April 1, 2019, was to be three ounces for all diets and the shepherd's pie portion was to be six ounces for all diets. Review of facility recipes for two items on the menu revealed matching portion sizes.

On April 2, 2019, at approximately 12:15 PM, the turkey loaf saved from lunch previous day was weighed using a digital scale by Registered Dietitian (RD) 1 and revealed a weight of 2.8 ounces.

An observation was made in the facility main kitchen on April 3, 2019, of the lunch meal tray line at 11:50 AM which revealed what appeared to be a small portion of salmon patty and potato wedges. It was observed that DS 1 was serving two small thin wedges of the potato. At 12:13 PM, RD 1 weighed one salmon patty which revealed weight of 2.5 ounces and a portion of the potato as served by DS 1 revealed a weight of 2.9 ounces. Review of facility Diet spreadsheet for all diets prior to the meal had revealed that the salmon patty was to be 3 ounces and the potato wedges 4 ounces. DS 1 was interviewed at this date/time as to how she knew what portions to serve for the items on the menu. DS 1 revealed that she was taught that when she came on board. DS 1 also revealed that she had been working for the facility for 23 years. DS 1 made no reference to menu sheets or the posting located next to the trayline which indicated portions for general categories of foods such as meat, vegetables, etc..

On April 3, 2019, at 12:16 PM surveyor met with RD 1 and PS 1 to share observations from the two lunch meals noted previously on April 1, and 3, 2019. PS 1 revealed that the extension sheet portion sizes reflected pre-cooked weights not "edible portion" (amount actually to be served). When asked what type/frequency of information/training provided to dietary staff prior to meals regarding portion sized to be served, RD 1 was unable to relate information and PS 1 revealed "often." RD 1 was unable to provide information as to why DS 1 thought portion for shepherds' pie was four ounces or for inconsistency in portion sizes. RD 1 was asked to provide information as to whether any residents were designated to receive larger/double etc. portions and rationale for what residents were to receive entrees in bowls. RD 1 revealed during this interview that residents would receive their entrees in bowls if it was their preference or if they were determined by therapy to do better with this.

No information was provided to indicate any residents were to receive large/double portions.

During an interview with Nursing Home Administrator (NHA) on April 4, 2019, at 11:40 AM, NHA revealed the expectation that food items on the menu would be served according to the menu guidelines

The facility failed to provide served food items to residents in the appropriate portion sizes determined according to the pre-planned menu (purpose of menu extension/spreadsheets is to dictate portion size to be served in order to meet dietary guidelines) for four menu items (salmon patty, potato wedges, turkey loaf, and also the shepherds' pie as amount served in the bowls was less than six ounces), failed to have a scale on sight to aid in managing appropriateness of served portions, failed to have a process in place for ensuring staff would know what portion sizes to provide.

28 Pa. Code: 211.6(a)(b) Dietary services.




















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

Preparation and submission of the Plan of Correction is required by state and federal law. This plan does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding.
Homeland Center appreciates the efforts of the state survey team to serve the best interest of Homeland Center Residents.
Immediate re-education of the Cook occurred on 4/3/19 regarding the serving of appropriate portion sizes according to the menu, paying particular attention to the weighing of meat, as the slice of turkey loaf was 2.8 oz. versus 3.0 oz. as stated on the menu. Failure to willingly comply with the established procedures associated to the weighing of meats according to the established process, will result in immediate correction, in addition to disciplinary action.
Immediate re-education of DS (1) occurred on 4/4/19 regarding the responsibility to ensure consistency with portion sizes when using varying serving dishes and utensils (i.e. plate vs. bowl). This will ensure all residents receive consistent portions in a timely manner and would remove the need for the department to produce additional food items such as ground salmon, which occurred that day.
In addition to daily supervision, DS (1) will be visually observed, two times weekly, thru 10/31/19, by the Director of Nutritional Services, Assistant Director of Nutritional Services, Dietary Purchasing/ Production Supervisor, or Registered Dietitian during the lunch tray line to ensure compliance with serving the appropriate portion size consistently, and according to the menu. Failure to willingly comply with the established procedures associated to appropriate portion size will result in immediate correction during tray line service, in addition to disciplinary action.
With no Residents being adversely affected by identified non-compliance, further intervention will occur in that, Residents on each unit, including dementia unit, will be surveyed to ensure they remain satisfied with the past and current portion sizes. This will occur no later than 4/19/19.
Procedure associated to ensuring adherence to the scheduled menu, regarding food portions, will be strengthened to ensure compliance.
An element of the daily meal meeting, will be either the Director of Nutritional Services, Assistant Director of Nutritional Services, or Dietary Purchasing/Production Supervisor, emphasizing the importance of providing accurate portion sizes with each meal, and accountability associated, according to the revised procedure.
Director of Nutritional Services, Assistant Director of Nutritional Services, Registered Dietitian, or Dietary Purchasing/Production Supervisor, in addition to Supervisor responsible for a specific meal, will audit Server on tray line for one random breakfast meal, one random lunch meal, and one random dinner meal, on a weekly basis to ensure consistent appropriate portion sizes, according to menu/production sheets, with consistent use of appropriate serving utensils, according to revised procedure. This will occur thru 10/31/19, unless compliance is not achieved, on an on-going basis, at which time audit will continue for additional 90 day periods until compliance is achieved.
In-service education will occur for all Nutritional Service staff members associated to proper production of Resident meals to ensure an understanding is obtained relative to the importance of accuracy for portion sizes, proper serving utensils, and scale to be utilized in the creation, preparation, and serving of Resident meals. This will occur on or before 4/30/19. In-service education will occur annually.
PS (1) (Dietary Purchasing/Production Supervisor) was immediately re-educated on 4/1/19 regarding the purpose and importance of having a working scale available in kitchen, at all times, to consistently ensure appropriate portion sizes. A new scale was immediately obtained and began to be utilized for the 4/1/19 dinner meal. A back-up scale was obtained on 4/10/19. In addition, PS (1) (Dietary Purchasing/Production Supervisor) was immediately re-educated as to responsibility associated to production, compliance with procedure, regulatory requirements, job description requirements, requirements and professional knowledge associated to food production, and adherence to scheduled menu regarding food portions.
A Quality Assurance Performance Improvement (QAPI), Performance Improvement Plan (PIP), was developed on 4/3/19, and shared with Surveyor, which identified immediate measures taken to ensure compliance with the process of delivering consistently accurate portion sizes, according to scheduled menu, to Homeland Center Residents. This further includes use of a Consultant Registered Dietitian, specializing in long term care food production, being included in the revised PIP on 4/11/19, to further ensure compliance. Consultant Registered Dietitian will begin on 4/24/19. The Administrative Assistant for QAPI, or designee, will audit one random breakfast meal, one random lunch meal, and one random dinner meal, on a weekly basis, on the tray line, to ensure accuracy of scheduled menu and food portions. This will include weighing of food portions and reviewing serving sizes to ensure accuracy as determined by the scheduled production sheet/menu. This will occur thru 10/31/19, unless compliance is not achieved, on an on-going basis, at which time audit will continue for additional 90 day periods until compliance is achieved.
Results of QAPI Performance Improvement Plan will be presented at the weekly Clinical/QAPI meeting. Further interventions will occur if determined 100% timely accuracy is not being achieved. Administrator will receive results of QAPI Performance Improvement Plan at weekly Clinical/QAPI meeting.
Administrator, Administrative Assistant responsible for QAPI, Director of Nutritional Services, Assistant Director of Nutritional Services, Registered Dietitian, and Dietary Purchasing/Production Supervisor will be responsible for on-going, consistent compliance.


483.20(g) REQUIREMENT Accuracy of Assessments: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(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 24 residents reviewed (Residents 40 and 89).

Findings Include:

Review of Resident 40's clinical record revealed diagnosis of depression (a depressed mood or loss of interest in activities, causing a significant impairment in daily life) and anxiety disorder (severe, ongoing anxiety that interferes with daily living).

Review of Resident 40's care plan revealed a care plan titled, Depression Care Plan, History of Depression, with a date initiated of December 5, 2017.

Review of Resident 40's current physician's orders reveals an order for Trazodone (an antidepressant medication) with a diagnosis of depression.

Review of MDS dated May 5, 2018, August 21, 2018, and January 30, 2019, section I5800 Depression (other than bipolar), does not have an X indicating that Resident 40 does not have depression.

During a staff interview on April 4, 2019 at 9:31 AM, Registered Nurse Assessment Coordinator 1 (RNAC) 1 revealed that it MDS dated May 5, 2018, August, 21, 2018, and January 30, 2019 should have indicated, in section I5800, that Resident 40 has depression.

Review of Resident 89's clinical record revealed diagnoses that included end stage renal disease (ESRD-a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) and hypertension (elevated blood pressure). Further review of Resident 89's clinical record revealed that she receives dialysis (the process of removing waste products and excess fluid from the body) Mondays, Wednesdays and Fridays.

Review of Resident 89's quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs), dated February 27, 2019, revealed that in section O, dialysis was not checked as being performed within the last 14 days.

During an interview with the RNAC 1 on April 3, 2019, at 10:19 AM she stated that dialysis should have been checked on the MDS.

During an interview with the Nursing Home Administrator and the Director of Nursing (DON) on April 3, 2019, at 2:40 PM the DON stated she was aware that dialysis was not checked on Resident 89's MDS.

28 Pa Code 211.12(d)(3)(5) Nursing Services












 Plan of Correction - To be completed: 04/22/2019

Preparation and submission of this Plan of Correction is required by state and federal law. This plan does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding.
Homeland Center appreciates the efforts of the state survey team to serve the best interest of Homeland Center Residents.
MDS Assessments dated May 5, 2018, August 21, 2018, and January 30, 2019, for Resident 40, corrected on 4/3/19.
In-service will occur for LPNAC, and entire MDS Department, to ensure understanding exists of the importance of having 100% accuracy when obtaining/entering information from MDS Worksheet associated to Resident 40.
In-service will occur for LPNAC, and entire MDS Department, to ensure understanding exists of the importance of having 100% accuracy when obtaining/entering information from MDS Worksheet associated to all Residents.
LPNAC, and entire MDS Department, will receive written notification of responsibility and requirement to obtain 100% accuracy in completion of all Resident MDS's.
RNAC will perform procedure to ensure 100% accuracy for MDS Section I5800, prior to MDS closure and submission. RNAC will review and incorporate all source information associated to MDS Section I5800 by comparing the MDS Worksheet and source information to final MDS, prior to closure and submission. Discrepancies will be immediately corrected. RNAC will create discrepancy log. All MDS's will be reviewed on a permanent basis.
MDS Assessment, for Resident 89, dated February 27, 2019 corrected on 4/3/19.
In-service will occur for LPNAC, and entire MDS Department, to ensure understanding exists of the importance of having 100% accuracy when obtaining/entering information from MDS Worksheet associated to Resident 89.
In-service will occur for LPNAC, and entire MDS Department, to ensure understanding exists of the importance of having 100% accuracy when obtaining/entering information from MDS Worksheet associated to all Residents.
LPNAC, and entire MDS Department, will receive written notification of responsibility and requirement to obtain 100% accuracy in completion of all Resident MDS's.
RNAC will perform procedure to ensure 100% accuracy for MDS Section O, prior to MDS closure and submission. RNAC will review and incorporate all source information associated to MDS Section O by comparing the MDS Worksheet and source information to final MDS, prior to closure and submission. Discrepancies will be immediately corrected. RNAC will create discrepancy log. All MDS's will be reviewed on a permanent basis.
Quality Assurance Performance Improvement (QAPI), Performance Improvement Plan, will be created. This will include Administrative Assistant for QAPI Coordination reviewing selected, submitted MDS's to ensure 100% accuracy for complete MDS, including MDS Section I5800 and Section O.
Results of QAPI Performance Improvement Plan and notations to discrepancy log will be presented at the weekly Clinical/QAPI meeting. Further interventions will occur if determined 100% accuracy is not being achieved. Administrator will receive results of QAPI Performance Improvement Plan at weekly Clinical/QAPI meeting.
Administrator, RNAC, and Administrative Assistant responsible for QAPI will be responsible for on-going, consistent compliance.


35 P. S. 448.809b LICENSURE Photo Id Reg:State only Deficiency.
(1) The photo identification tag shall include a recent photograph of the employee, the employee's name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.


Observations:


Based on observation and staff interview it was determined the facility failed to ensure employee photo identification includes a recent employee photo, employee name, employee title and name of the health care facility or employment agency for two of two staff persons identified.

Findings Include:

An observation on April 1, 2019 at 6:49 AM revealed the license practical nurse (LPN) 1 wearing no facility issued identification badge. An immediate interview with LPN 1 revealed she left her identification badge at home.

An observation on April 1, 2019 at 7:18 AM revealed a nursing assistant (NA) 1 also wearing no agency issued identification badge. An immediate interview with NA 1 revealed he forgot to wear his identification badge to work.

Review of the facility's Employee Badge Policy, with an effective date of September 2015, reads, in part, "regulations mandate that the photo identification badge of anyone providing direct Patient/resident care must also display the title on the front of the badge."

An interview with the Nursing Home Administrator (NHA), on April 3, 2019 at 1:12 PM revealed staff should be wearing their identification badges, however administrative staff are not available 24 hours a day to provide replacements.







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

Preparation and submission of the Plan of Correction is required by state and federal law. This plan does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding.
Homeland Center appreciates the efforts of the state survey team to serve the best interest of Homeland Center Residents.
LPN (1) was wearing label made identification that stated her first and last name and her position. LPN (1) was re-educated on the Badge policy and the importance of adhering to its requirements on 4/1/19. LPN (1) obtained a new badge on 4/1/19.
Agency NA (1) was wearing label made identification that stated his first and last name and his position. After being approached by Surveyor, went to his work bag to do a deeper search for his badge. Search resulted in his badge being found and immediately placed on his person. Agency NA (1) was educated as to the regulatory requirement to wear proper identification while providing care at Homeland Center.
The Badge policy was immediately updated to include the requirement of a current photo on a temporary badge, and the process to create one.
Direct Care staff will be re-educated, as to Badge policy, to ensure they understand the regulatory requirements associated to wearing proper identification while providing care and steps necessary to obtain a temporary badge. This in-service will be completed on or before 4/26/19.
Agency staff will be provided Badge policy and the regulatory requirement associated to wearing proper identification while providing direct care, with the requirement they educate staff performing duties at Homeland Center of this requirement.
Agency's contracted to provide temporary staff will receive notification stating they will are required to send us a color copy of their staff person's identification badge, which includes the agency name, with the package of credentials already required. This document will be used as a temporary badge. The copy will be placed in a vinyl badge holder with a clip, which includes a hang tag, identifying them as an Agency CNA or an Agency LPN. The temporary badge will be returned to the Homeland Center Supervisor at the end of the shift.
Homeland Center staff requiring a temporary badge, outside of normal business hours, will be required to immediately report to the Nursing Supervisor's Office to obtain a temporary badge that contains the regulatory required information. Color photocopies of the direct care staff will be maintained in the Nursing Supervisor's office. These copies will be utilized to make a temporary badge. The copy will be placed in a vinyl badge holder that is stamped with Homeland Center's logo, along with a clip that includes a hang tag identifying them as a CNA or an LPN. The temporary badge will be returned to the Homeland Center Supervisor at the end of the shift.
A Quality Assurance Performance Improvement (QAPI), Performance Improvement Plan (PIP), will be developed to ensure compliance with the Badge Policy, and process for creating a temporary badge when needed. The Administrative Assistant for QAPI and/or Designee will perform three random audits weekly, one per shift, of all direct care staff, to ensure they are wearing proper identification. This will occur thru 6/30/19, unless compliance is not achieved, on an on-going basis, at which time audit will continue for additional 90 day periods until compliance is achieved.
Results of QAPI Performance Improvement Plan will be presented at the weekly Clinical/QAPI meeting. Further interventions will occur if compliance is not achieved. Administrator will receive results of QAPI Performance Improvement Plan at weekly Clinical/QAPI meeting.
Administrator, Administrative Assistant responsible for QAPI, and Director of Human Resources/Corporate Compliance will be responsible for on-going, consistent compliance.



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