|§483.80 (h) COVID-19 Testing. The LTC facility must test residents and facility staff, including|
individuals providing services under arrangement and volunteers, for COVID-19. At a minimum,
for all residents and facility staff, including individuals providing services under arrangement
and volunteers, the LTC facility must:
§483.80 (h)((1) Conduct testing based on parameters set forth by the Secretary, including but not
(i) Testing frequency;
(ii) The identification of any individual specified in this paragraph diagnosed with
COVID-19 in the facility;
(iii) The identification of any individual specified in this paragraph with symptoms
consistent with COVID-19 or with known or suspected exposure to COVID-19;
(iv) The criteria for conducting testing of asymptomatic individuals specified in this
paragraph, such as the positivity rate of COVID-19 in a county;
(v) The response time for test results; and
(vi) Other factors specified by the Secretary that help identify and prevent the
transmission of COVID-19.
§483.80 (h)((2) Conduct testing in a manner that is consistent with current standards of practice for
conducting COVID-19 tests;
§483.80 (h)((3) For each instance of testing:
(i) Document that testing was completed and the results of each staff test; and
(ii) Document in the resident records that testing was offered, completed (as appropriate
to the resident’s testing status), and the results of each test.
§483.80 (h)((4) Upon the identification of an individual specified in this paragraph with symptoms
consistent with COVID-19, or who tests positive for COVID-19, take actions to prevent the
transmission of COVID-19.
§483.80 (h)((5) Have procedures for addressing residents and staff, including individuals providing
services under arrangement and volunteers, who refuse testing or are unable to be tested.
§483.80 (h)((6) When necessary, such as in emergencies due to testing supply shortages, contact state
and local health departments to assist in testing efforts, such as obtaining testing supplies or
processing test results.
Based on a review of the facility's COVID-19 testing, standards established by the Centers for Medicare & Medicaid Services, and staff interview, it was determined the facility failed to timely conduct testing of three residents exhibiting signs and symptoms of COVID-19 out of 20 sampled residents. (Resident 69, 74, and 54)
According to the Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Survey & Certification Group QSO-Memo - 20-38-NH initially dated August 26, 2020 and revised on September 10, 2021, residents either vaccinated or unvaccinated who exhibit signs and symptoms of COVID-19 must be tested for COVID-19.
A review of Resident 69's clinical record revealed that on October 5, 2021, at 9:00 PM, the resident had a fever of 101.9 degrees Fahrenheit at 5:20 PM. Tylenol was administered, and temperature rechecked. The resident had a temperature of 103.3 degrees Fahrenheit in right ear and 102.3 degrees Fahrenheit in left ear.
No documentation was noted that the resident was tested for COVID-19 despite exhibiting signs and symptoms.
A review of Resident 74's clinical record revealed on October 18, 2021, at 5:13 PM, the resident noted with to be wheezing, had diminished lung sounds and a chronic cough.
A review of Resident 74's clinical record revealed no documentation the resident was tested for COVID-19 despite exhibiting signs and symptoms.
A review Resident 54's clinical record revealed on June 29, 2021 the resident had a sore throat and a low grade temperature. The facility notified the CRNP (certified registered nurse practitioner) who indicated to monitor the resident and report if no improvement.
There was no documentation in Resident 54's clinical record that the resident was tested for COVID-19 despite exhibiting signs and symptoms.
Interview with Director of Nursing on October 21, 2021, at approximately 1:00 PM conformed there was no documented evidence in the clinical record that the residents exhibiting potential signs and symptoms of COVID-19 were promptly tested.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 211.12 (c) Nursing services.
| ||Plan of Correction - To be completed: 12/14/2021|
There were no residents in the facility that experienced adverse consequences, as a result of not being tested for COVID-19, when exhibiting potential signs/symptoms of the disease. None were confirmed as having COVID-19.
Moving forward, residents 69, 74, 54 and all residents who exhibit signs and symptoms of COVID-19 will be tested for COVID-19, regardless of the physician's order for monitoring.
The licensed nursing staff is being re-educated regarding the need to test all residents, regardless of vaccine status, who are potentially symptomatic for COVID-19.
The Assistant Director of Nursing/Infection Prevention Nurse or designee will complete a Quality Assessment Performance Improvement (QAPI) project to ensure that all residents who have potential signs/symptoms of COVID-19 are tested. This study will continue until 100% compliance has been achieved for 3 consecutive months. Results will be shared at the monthly QAPI/Infection Prevention/Safety & Compliance Meeting and if indicated corrective action will be taken.