Pennsylvania Department of Health
TRANSITIONS HEALTHCARE NORTH HUNTINGDON
Patient Care Inspection Results

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TRANSITIONS HEALTHCARE NORTH HUNTINGDON
Inspection Results For:

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TRANSITIONS HEALTHCARE NORTH HUNTINGDON - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance, and Abbreviated Survey in response to three complaints completed on May 30, 2025, it was determined that Transitions Healthcare North Huntingdon 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.


 Plan of Correction:


483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions: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.
§483.10(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.
Observations:
Based on review of clinical record and staff interviews, it was determined that the facility failed to inform a resident's representative in advance of the proposed care, including the risk and benefits of the prescribed medication for one of three residents (Resident R43).

Finding include:

Review of the facility's policy, "Change of Condition," with a review date of 4/1/25, and 4/1/24, reported that the facility must notify the resident's representative of the change and any changes made to the resident's plan of care and document in the medical record. Assist with any contacts desired between the family, resident, and Physician/CRNP (Certified Registered Nurse Practitioner) within HIPPA guidelines. Attempt to contact the resident representative at frequent intervals, until notified of the change and interventions, and document all attempts to notify resident representative.

Review of Resident R43's Minimum Data Set (MDS - periodic assessment of resident care needs), dated 4/22/25, indicated diagnoses of traumatic subarachnoid hemorrhage without loss of consciousness (bleeding between the brain and the tissue covering the brain), dysphagia (difficulty swallowing), diabetes (too high or too low of blood sugar), seizures (abnormal activity in the brain that can cause jerking movements, loss of consciousness, blank stares or other symptoms).

Further review of the MDS indicated the resident's Brief Interview for Mental Status assessment (BIMS) was 99 indicating the resident has a severe impairment where they can not complete the interview to obtain a value for mental status.

Review of prior physician order dated 4/9/25, indicated Ativan 0.5mg Oral Tablet, Give 1 tablet (0.5mg) once a day for anxiety.

Review of the physician orders dated 4/18/25, Ativan 0.5mg Oral Tablet, Give 0.5mg in a.m. Give 0.25 mg at bedtime for anxiety.

Review of the physician orders dated 4/18/25, revision 4/28/25, Ativan 0.5mg Oral Tablet, Give 0.25 mg at bedtime for anxiety.

Review of the physican orders dated 12/20/24, Haldol 2mg/1ml, Give 0.5 ml Oral Solution twice a day.

Review of the physician orders dated 3/13/25, Haldol 2mg/1ml, Give 0.5 ml once a day at bedtime, order was discontinued on 3/20/25.

Review of Resident R43's nurse progress notes April 19, 2025-May 2025 and Psychiatry recommendations from April 2025-May 2025 revealed no evidence that the resident's husband or other representative was notified of the new orders, discussed the advantage and disadvantage of medication decrease and alternative options.

During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 5/30/25 at 11:22 a.m., confirmed that the facility failed to inform resident's representative in advance of the proposed care, including the risk and benefits of the prescribed medication for Resident R43 as required.

28 Pa Code 201.29(j) Resident Rights.

28 Pa Code 211.10(c) Resident Care policies.

28 Pa Code 211.12(d)(1) Nursing Services.


 Plan of Correction - To be completed: 06/25/2025

Preparation and or evaluation of the following plan of correction set forth in this document does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provisions of federal and state law.
Nursing will complete a current psychotropic medication review with Resident R43's family and discuss the advantages and disadvantages of medications.
Nursing will complete a 30-day lookback audit of psychotropic medication orders to ensure resident/resident representatives have been notified of any medication changes.
The Director of Nursing will complete licensed staff education on the change in condition policy focusing on resident/responsible party notification of psychotropic medication initiation/decreases/discontinuations.
The Director of Nursing/designee will audit new physician orders for psychotropic medications five days a week for four weeks to ensure resident/responsible party notification of psychotropic medication initiation/decreases/discontinuations has occurred and is documented in the medical record.
Audits will be taken to QAPI for review/discussion.

483.20(f)(5), 483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:
Based on review of facility policies, clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of four residents (Resident R69)

A review of the facility policy "Administration Procedures For All Medications" dated 4/1/25, indicated medications will be administered in a safe and effective manner and after administration document in the MAR (medication administration record) or TAR (treatment administration record) as necessary.

A review of the clinical record indicated that Resident R69 was admitted to the facility on 1/6/24, with diagnoses that included heart disease, dementia, and asthma.

A review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/13/25, indicated the diagnoses remained current.

A review of Resident R69's physician orders dated 1/23/25, indicated to administer oxygen via n/c (nasal cannula) at 4L (liters) per minute continuously every shift.

A review of Resident R69's MAR dated May 2025 did not include documentation that the resident received oxygen as ordered on 5/4, 5/9, 5/13, 5/14, 5/15, 5/20, 5/22, 5/23, and 5/27/25.

During an interview on 5/28/25 , at 1:45 p.m. the Nursing Home Administrator confirmed the above findings, and the facility failed to make certain that medical records on each resident are complete and accurately documented for Resident R69.

28 Pa. Code: 211.5(f)(g)(h) Clinical records.





 Plan of Correction - To be completed: 06/25/2025

No adverse outcome occurred from resident R69 having missed documentation for oxygen administration.
Each shift RN supervisor will monitor MAR/TAR completion by utilizing the Point Click Care Dashboard to check compliance before the shift is over.
The Director of Nursing will complete RN supervisor education on documentation monitoring and licensed staff education on completing MAR/TAR documentation before the end of their shift.
The Director of Nursing/designee will audit MAR/TAR documentation completion five days a week for four weeks to ensure there are no missing entries.
Audits will be taken to QAPI for review/discussion.


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