Pennsylvania Department of Health
MONTICELLO HOUSE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MONTICELLO HOUSE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare Recertification, State Licensure and Civil Rights Compliance Survey completed on May 10, 2024, it was determined that Monticello House 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 of the Health survey process

Plan of Correction:

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

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.

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on observation, clinical record review, and staff interviews, it was determined the facility failed to ensure enhanced barrier precautions (EBP-An infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for five of five reviewed (Residents 10, 21, 50, 56, and 58).

Findings include:

Clinical records review revealed Resident 10 was admitted to the facility with a diagnosis of left sub gluteal abscess. The resident had an order for IV (Intravenous- a medication administered through a needle or tube inserted into a vein) antibiotics.

An observation conducted on March 7, 2024, at 11:00 a.m., revealed a central line catheter to Resident 10 ' s right upper chest.

An observation of Resident 10 ' s room on the first three days of the survey failed to reveal evidence of EBP signage or PPE.

An observation conducted on May 10, 2024, at 11:01 a.m., revealed Resident 21 had a pressure ulcer to the sacrum. The same observation revealed resident had an indwelling foley catheter (A flexible tube inserted into the bladder for removing fluid).

An observation of Resident 10 ' s room on the first three days of the survey failed to reveal evidence of EBP signage or PPE.

A review of Resident 50 ' s diagnosis list includes a Gastrostomy Tube (GT- A medical device used to provide nutrition to people who cannot obtain nutrition by mouth).

An observation of Resident 10 ' s room on the first three days of the survey failed to reveal evidence of EBP signage or PPE.

A review of Resident 56 ' s diagnosis list includes a Gastrostomy Tube.

An observation of Resident 10 ' s room on the first three days of the survey failed to reveal evidence of EBP signage or PPE.

A review of Resident 58 ' s clinical records revealed that the resident had an indwelling Foley catheter.

An observation of Resident 10 ' s room on the first three days of the survey failed to reveal evidence of EBP signage or PPE information regarding the facility ' s EBP process/procedures.

An interview with non-licensed Employees E3 and E4 was conducted on May 10, 2024. Both employees were unable to provide

An interview with the Director of Nursing on May 10, 2024, at 12:30 p.m., was conducted. The DON reported that the facility had not implemented the EBP process and was still in the process of educating staff.

The above was discussed with the Nursing Home Administrator on May 10, 2024, at 1:45 p.m.

28 Pa. Code 201.18(b)(1) Management

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 06/17/2024

Residents identified were placed on Enhanced Barrier Precautions

All current residents will be reviewed to see if they meet the criteria for Enhanced Barrier Precautions. Any resident identified will have their precaution status updated. Nursing personnel will be educated on Enhanced Barrier Precautions

The Director of Nursing/designee will conduct a random observation of 5 staff members providing care to a resident on Enhanced Barrier Precautions monthly for the next 6 months.

The results of these Audits will be reviewed quarterly during our QAPI Meetings for the next 2 quarters.

Disclaimer:
Preparation and /or execution of this entire Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this Statement of Deficiencies. The entire Plan of Correction is prepared and/or executed solely because it is required by the provisions of Federal and State laws.

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