|§483.10(f)(4) The resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident.|
(ii) The facility must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident's right to deny or withdraw consent at any time;
(iii) The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident's right to deny or withdraw consent at any time;
(iv) The facility must provide reasonable access to a resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time; and
(v) The facility must have written policies and procedures regarding the visitation rights of residents, including those setting forth any clinically necessary or reasonable restriction or limitation or safety restriction or limitation, when such limitations may apply consistent with the requirements of this subpart, that the facility may need to place on such rights and the reasons for the clinical or safety restriction or limitation.
Based on observation, review of CMS guidance, select facility policy and documentation and interviews with residents, it was determined that the facility failed to allow residents to receive visitors of their choosing, at time desired by six of 26 residents reviewed (Residents 6, 126, 124, 131, 45, and 62).
Review of CMS (Centers for Medicare and Medicaid Services) Memorandum QSO-20-39-NH, "Nursing Home Visitation - COVID-19 (Revised)" dated revised November 12, 2021, revealed that, "Visitation is now allowed for all residents at all times." Continued review revealed, "Facilities must allow indoor visitation at all times and for all residents as permitted under the regulations ... Facilities can no longer limit the frequency and length of visits for residents, the number of visitors, or require advance scheduling of visits." Further review revealed "Effective Date: Immediately" for this Memorandum.
During observations in the facility on November 30, 2021, at approximately 8:00 a.m., signage was observed outside of elevators dated August 23, 2021, stating that due to local positivity rates all visits are restricted to the MPR (Multipurpose Room) or the patio and "there will be no visits on the unit."
Review of the facility's current visitation policy revealed it had not been updated to reflect the most recent QSO memorandum revised 12, 2021.
During an interview with Resident 6, he stated he was tired of not being allowed to have visitors in his room. The resident stated "I miss my friends and family. I feel like a prisoner."
During a group meeting held on December 1, 2021 at 10:00 a.m., with five alert and oriented residents (Residents 126, 124, 131, 45, and 62) all residents in attendance stated they were not allowed to have visitors in their rooms and they wanted visits at locations of their choosing.
Interview on December 1, 2021, at 2:00 p.m. the Nursing Home Administrator (NHA) confirmed that the facility had not updated the facility policy regarding visitation based on the updated guidance issued by CMS (Memorandum QSO-20-39-NH Revised November 12, 2021).
28 Pa Code 201.18 (e)(1)(2) Management
28 Pa Code 201.29 (a)(d) Resident rights
| ||Plan of Correction - To be completed: 01/11/2022|
1. Residents 6, 126, 124, 131, 45 and 62 have been made aware that we will arrange for visitation in resident areas. Families were made aware that visitation can be safely set up on the units.
2. GMVC Residents have been made aware that we will arrange for visitation in resident areas. Families were made aware that visitation can be safely set up on the units.
3. Pennsylvania Veterans' Home (PVH) policy and has been updated to allow visitation to take place in resident areas. The policy has been in-serviced to facility staff.
4. QA will audit visitation by interviewing a random sample of 5 residents/family members per week X 8 to see if they are aware of PVH policy. The results of the audit will be turned in to the QAPI team for review.
5. January 11, 2022