Pennsylvania Department of Health
BRIGHTON REHABILITATION AND WELLNESS CENTER
Patient Care Inspection Results

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BRIGHTON REHABILITATION AND WELLNESS CENTER
Inspection Results For:

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BRIGHTON REHABILITATION AND WELLNESS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
A COVID-19 Focused Emergency Preparedness Survey was conducted by The Department of Health (DOH) on December 19, 2022. Brighton Rehabilitation and Wellness Center was in compliance with 42 CFR 483.73 related to E-0024(b)(6).


 Plan of Correction:


Initial comments:

Based on a COVID-19 Focused Infection Control Survey completed on December 19, 2022, it was determined that Brighton Rehabilitation and wellness Center 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:


483.80(i)(1)-(3)(i)-(x) REQUIREMENT COVID-19 Vaccination of Facility Staff: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.
483.80(i)
COVID-19 Vaccination of facility staff. The facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine.

483.80(i)(1) Regardless of clinical responsibility or resident contact, the policies and procedures must apply to the following facility staff, who provide any care, treatment, or other services for the facility and/or its residents:
(i) Facility employees;
(ii) Licensed practitioners;
(iii) Students, trainees, and volunteers; and
(iv) Individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement.

483.80(i)(2) The policies and procedures of this section do not apply to the following facility staff:
(i) Staff who exclusively provide telehealth or telemedicine services outside of the facility setting and who do not have any direct contact with residents and other staff specified in paragraph (i)(1) of this section; and
(ii) Staff who provide support services for the facility that are performed exclusively outside of the facility setting and who do not have any direct contact with residents and other staff specified in paragraph (i)(1) of this section.

483.80(i)(3) The policies and procedures must include, at a minimum, the following components:
(i) A process for ensuring all staff specified in paragraph (i)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents;
(iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19;
(iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (i)(1) of this section;
(v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC;
(vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law;
(vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the facility has granted, an exemption from the staff COVID-19 vaccination requirements;
(viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains:
(A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and
(B) A statement by the authenticating practitioner recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications;
(ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and
(x) Contingency plans for staff who are not fully vaccinated for COVID-19.

Effective 60 Days After Publication:
483.80(i)(3)(ii) A process for ensuring that all staff specified in paragraph (i)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations;
Observations:
Based on reviews facility policy and employee vaccination information, and staff interview, it was determined that the facility failed to ensure that medical exemptions were only issued for contraindications related to recognized clinical reasons for one of three employees (Employee E1).

Findings include:

Review of the facility's "COVID-19 Vaccinations Policy" dated 12/8/21, indicated the medical exemption form must include all documentation confirming the recognized clinical contraindications to COVID-19 vaccinations. This documentation must contain all information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications.

Review of the " Medical Exemption from Vaccination" form dated 11/24/21, indicated Employee E1 received a medical exemption for natural immunity (condition from having a Covid-19 previous infection where there is an increased level of special antibodies in the blood that fights reinfection).

Review of the CDC "Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the United States" dated 4/21/22, which provides information on contraindication and precautions, does not include Natural Immunity as contraindications to receiving the COVID-19 vaccine.

Interview on 12/20/22, at 4:30 p.m. the Nursing Home Administrator, Director of Nursing, and the Infection Control Nurse E2 confirmed that the facility failed to ensure that medical exemptions were only issued for contraindications related to recognized clinical reasons for one of three employees (Employee E1).

28 Pa. Code 201.18 (b)(1)(3) Management.

28 Pa. Code 201.18 (b)(1)(3) Management.


 Plan of Correction - To be completed: 01/15/2023

1. Facility administration met with employee E1. A vaccine exemption was requested and granted based on sincerely held religious belief.

2. An audit was conducted of employee medical exemptions with no further issues identified.

3. Infection control nurse was provided education on medical exemptions by director of nursing.

4. New employee medical vaccine exemption requests will be audited weekly x 3 weeks, then monthly x 2 months to ensure compliance with exemption guidelines.


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