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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

TRANSITIONS HEALTHCARE NORTH HUNTINGDON
Inspection Results For:

There are 148 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.


TRANSITIONS HEALTHCARE NORTH HUNTINGDON - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and Complaint survey completed on June 7, 2024, it was determined that Transitions Healthcare North Huntington 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(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:

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(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

Observations:
Based on review of resident group interview, Ombudsman interview, and observations it was determined that the facility failed to provide a private space for the resident group for ten of ten residents (GR100, GR101, GR102, GR103, GR104, GR105, GR106, GR107, GR108, and GR109).

Findings include:

During a group interview on 6/5/24, at 1:30 p.m. a Resident Group meeting was conducted in the facility dining room. Signage was posted by the facility on the doors of both sides of the dining room, indicating that a private resident group was being conducted, and not to enter.

During the group interview, facility staff entered the group 13 times, to utilize the dining room to proceed from one side of the building to the other. When a facility staff member who entered the dining room was asked by the surveyor if signage was posted asking for staff not to enter the room, she confirmed that it was. When asked why she entered, she stated, "To go to the front office."

After this interruption, the surveyor facilitating the group interview exited the room, informed the Nursing Home Administrator (NHA) of the continued interruptions, and requested that the group was provided privacy.

While continuing to conduct the group interview, a staff member was observed through the window of the dining room door, standing directly on the other side, which allowed her to hear the group discussion.

The resident group interview was again paused to allow the surveyor to instruct the staff member that she cannot listen to the group meeting. The staff member confirmed that she was posted there to not allow any further entrance of staff to the meeting. The surveyor then had to request that she step further back, and gestured to an area approximately 10-15 feet from the door, and indicated that she can still prevent interruptions from there, without having to be within inches of the door.

When the group was asked if the interruptions usually occurred during their Resident Council groups, Group Resident GR108 responded, "Welcome to our world."

During an interview with the Ombudsman on 6/6/24, at 12:05 p.m., she confirmed that she has been present in previous resident groups that have been interrupted and further confirmed that the trainings she holds for resident peers had also been interrupted.

During an interview on 6/7/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility layout has a connecting hallway, and staff do not need to utilize the dining room to proceed from one side of the building to the other and further confirmed that the facility failed to provide a private space for the resident group for ten of ten residents,

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

Plan of Correction - To be completed: 06/27/2024

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.

The facility cannot go back to correct the interruptions that occurred during the resident group that was held during annual survey. System change has been made to resolve the interruptions.

Prior to the resident group, an announcement will be made that resident group will be starting in the dining room. Staff that are in this area will then relocate to a different part of the facility. Bright pink signs have been created and will be posted on sign stands that will be placed outside the two sets of doors to enter the dining room. Social Services will stand 15 feet away from the closed doors and monitor outside the doors to redirect staff while meetings are occurring. .

The NHA will provide education to staff on resident/family group policy and procedure.

The NHA will audit/monitor the resident group meeting monthly for three months. Any staff that does not comply and enters the dining area during the meeting will be disciplined.

Audits will be taken to QAPI for review/discussion.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:

§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Observations:
Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for four of five residents reviewed (Resident R23, R65, R84, and R87).

Findings include:

A review of the facility "Advanced Directive and Advanced Care Planning" reviewed 9/23/23, 1/10/24, and 4/10/24, indicated it is the policy and intent of the facility to inform and provide residents with written information regarding their right to formulate advanced directives for the purpose of prospectively identifying a healthcare decision maker, clarifying treatment preferences, and developing individualized goals of care near end of life.

A review of the medical record indicated Resident R23 was admitted to the facility on 11/17/21, with diagnoses that included diabetes, depression, and high blood pressure.

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R23 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R65 was admitted to the facility on 9/14/21, with diagnoses that included diabetes, depression, and high blood pressure.

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R65 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R84 was admitted to the facility on 4/23/22, with diagnoses that included pulmonary fibrosis (lungs become scarred and damaged causing difficulty in breathing), reduced mobility, and obesity.

A review of the clinical record failed to reveal an advance directive or documentation that Resident R84 was given the opportunity to formulate an Advance Directive.

A review of the clinical record indicated Resident R87 was re-admitted to the facility on 9/26/22, with diagnoses that included scoliosis (abnormal curvature of the spine), difficulty speaking, and diabetes.

A review of the clinical record failed to reveal an advance directive or documentation that Resident R87 was given the opportunity to formulate an Advance Directive.

During an interview on 6/7/24, at 9:40 a.m. Social Worker Employee E2 confirmed that the clinical record did not include documentation that Resident R23, R65, R84, and R87 were afforded the opportunity to formulate Advanced Directives.

28 Pa. Code: 201.29(b)(d)(j) Resident rights.

Plan of Correction - To be completed: 06/27/2024

Social Service will meet with and give residents R23,R65,R84,R87 an opportunity to formulate an advanced directive. Documentation of meetings and decisions will be completed in the medical record.

Social Services will complete house audit of current residents for advanced directives. Any resident that does not have documentation of an advanced directive or the opportunity to formulate one will be provided education and an opportunity to formulate one. Social Service will document .

The NHA will provide education to the Social Services Department on formulating advanced directives . Education will include documentation in the medical record.

The NHA/Designee will audit new admission weekly for 4 weeks checking for advance directives or documentation that the resident was given the opportunity to formulate an Advance Directive.

Audits will be taken to QAPI for review/discussion.

483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing:

§483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

§483.20(b) Comprehensive Assessments
§483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

§483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.

Observations:
Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for seven of 20 residents (Resident R9, R13, R17, R26, R36, R64, and R92).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that an admission MDS assessment was to be completed no later than 14 days following admission (admission date plus 13 calendar days), and an annual MDS assessment was to be completed no later than the Assessment Reference Date (ARD).

Resident R9 had an admission date of 2/7/24, with an MDS completion due date of 2/21/24.

Resident R13 had an ARD of 3/4/24, with an MDS completion date of 3/21/24.

Resident R17 had an admission date of 2/7/24, with an MDS completion due date of 2/21/24.

Resident R26 had an admission date of 4/22/24, with an MDS completion due date of 5/6/24.

Resident R36 had an ARD of 3/8/24, with an MDS completion date of 3/25/24.

Resident R64 had an ARD of 3/7/24, with an MDS completion date of 3/25/24.

Resident R92 had an admission date of 3/29/24, with an MDS completion due date of 4/14/24.

During an interview on 6/7/24, at 9:52 a.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed the above late MDS assessments, stating that the previous RNAC left without providing notice, and was found to have multiple assessments overdue.

During an interview on 6/7/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that MDS assessments were completed in the required time frame for seven of 20 residents.

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

Plan of Correction - To be completed: 06/27/2024

The facility cannot go back and change completion dates for residents R9,R13,R17,R26,R36,R64. No adverse outcome occurred from assessments being completed untimely.

The facility has replaced the RNAC who resigned and is hiring an additional LPNAC. Until LPNAC starts, the Regional Reimbursement Coordinator will provide support for completion of MDS assessments.

The Regional Reimbursement Coordinator will conduct training with the RNAC/LPNAC department on MDS completion requirements and submission requirements per RAI guidelines.

Regional Reimbursement Coordinator/Designee will audit new admissions and residents due for annual assessments weekly for 4 weeks to ensure that admission MDS assessments are completed within 14 days following admission and annual MDS assessments are completed within 14 days of the assessment reference date.

Audits will be taken to QAPI for review/discussion.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

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.

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:
Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications and medication supplies were properly stored and/or disposed of in one of two medication rooms (Orchards medication room).

Findings include:

Review of the facility policy Storage of Medications dated 4/1/24, indicated medications are and biologicals are stored safely, securely, and properly, following manufacturer's recommendations.

During an observation on 6/4/24, at 11:20 a.m. of the Orchards medication room, the following was observed:
-(57) vacutainers with an expiration date of 5/31/24.
-(1) intravenous access (IV) start kit with an expiration date of 10/31/23.
-(1) IV start kit with an expiration date of 12/31/23.
-(2) IV start kits with an expiration date of 5/31/24.
-(13) Povidone-iodine swabsticks with an expiration date of 1/31/24
-(10) disposable scalpels with an expiration date of 7/1/23.
-(1) bottle of glucometer testing solutions with an expiration date of 11/14/23.
-(1) vial of insulin, opened and undated.

During an interview on 6/4/24, at 11:30 a.m. the Director of Nursing confirmed the above items were expired.

During an interview on 6/7/24, at approximately 1:00 p.m., the Nursing Home Administrator confirmed that the facility failed to make certain that medications and medication supplies were properly stored and/or disposed of in one of two medication rooms.

28 Pa. Code: 201.14 (a) Responsibility of licensee.

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

28 Pa. Code: 211.9 (a)(1) Pharmacy services.

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

Plan of Correction - To be completed: 06/27/2024

Items identified during survey that were in stock past expiration dates (vacutainers, IV start kits, Povidine-iodine swabsticks, disposable scalpels, bottle of glucometer testing solutions, and insulin) were discarded when identified.

The DON will complete full medication room audits and discard any other items identified as in stock past their expiration date.
The DON will conduct education with the Central Supply clerk on how to audit medication rooms weekly and discard items approaching expiration dates.
The DON will conduct Licensed Staff education on the storage of biologicals policy and procedure.
The DON/Designee will audit medication rooms weekly for 4 weeks to ensure all items in stock are not past their expiration date.
Audits will be taken to QAPI for review/discussion.

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