Nursing Investigation Results -

Pennsylvania Department of Health
BELAIR HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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BELAIR HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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BELAIR HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an abbreviated survey in response to a complaint completed on January 10, 2020, it was determined that Belair Healthcare and Rehabilitation 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 for the Health portion of the survey process.


 Plan of Correction:


483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff: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.
483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e)

This includes:
483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who-
(i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is:
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.
Observations:
Based on a review of facility policy, facility documents, and staff interview, it was determined that the facility failed to employ staff with the the required skills and competencies to carry out the daily functions of the Dietary Department (Kitchen Manager Employee E1).

Findings include:

A review of facility policy "Food & Nutritional Services Department Personnel" dated 1/31/19, indicated that the Nutrition Services Manager qualifications include completion of an approved educational program as required by regulation and state law.

During an interview on 1/4/19, at 10:39 a.m. Kitchen Manager Employee E1 indicated that her only dietary credential was ServSafe (a restaurant associated food and beverage safety training and certificate program).

During an interview on 1/4/19, at 11:30 a.m. the Registered Dietitian Employee E2 confirmed that she works four days per week, approximately 32 - 35 hours, at the facility.

During an interview on 1/4/19, at 12:45 a.m. the Kitchen Manager Employee E1 indicated that the Registered Dietitian spends minimal time managing the facility kitchen.

During an interview on 8/15/19, at 4:15 p.m. the Nursing Home Administrator confirmed that Kitchen Manager Employee E1 failed to meet the requirements for a food service manager.

28Pa. Code: 211.6(c)(d) Dietary services.


 Plan of Correction - To be completed: 02/18/2020

- Dietary manager has been enrolled, as of January 6th 2020, in an accredited Certified Dietary Manager course and doing proctored hours under the direction of our Registered Dietician.
- Registered Dietician is main manager of the operations of the facility kitchen and practices working 35+ hours a week
- NHA or designee will educate Dietary manager and Registered Dietician on position duties and expectations while manager is completing CDM training course.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on a review of facility policies and documents, observations and staff interviews, it was determined that the facility failed to dispose of expired food products and make certain that equipment was properly sanitized in the Main Kitchen (Main Kitchen).

Findings include:

A review of the facility policy "Food Storage" dated 1/31/19, indicated all foods are dated upon receipt and that staff should check expiration date of milk and discard outdated product daily.

A review of the facility policy "Ware washing" dated 1/31/19, indicated that for mechanical warewashing the temperature of the dish machine will be recorded three times daily. Manual ware washing is completed by utilizing a Three Compartment Sink Method, the chemical strength of the sanitizing solution is tested by utilizing a test strip and recording on the sanitizing log.

A review of the facility policy "Safety and Sanitation" dated 1/31/19, indicated food and nutrition services employees will be trained on sanitation procedures.

During an observation of the Main Kitchen on 1/4/20, at 10:05 a.m. through 10:33 a.m., the following was identified:
-Dietary cook, Employee E3 stated that the food thermometer was broken, and she was unable to take food temperatures.
-The sanitizing sink log failed to reveal documenation for
1/1/20: breakfast, lunch, dinner
1/2/20: breakfast, lunch, dinner
1/3/20: breakfast, lunch
1/4/20: breakfast
-When asked to test the prepared sanitizing solution in the three-compartment sink, Cook Employee E3 was unable to locate test strips at that time.
-Dietary Aide Employee E4 was operating the dish machine, and unable to state if the dish machine was a high temperature or chemical sanitizing dish machine.
-(2) 8 ounce lactose free milk with use by dates of 12/2/19, and 12/23/19
-(1) 4 ounce orange juice with a use by date of 12/25/19
-(1) carton thickened pomegranate berry thickened water, with an open date of 9/10/19. Printed use direction on the carton indicate to use within seven days of open date.
-Dietary Aide Employee E4 demonstrated the process for testing the dish machine temperature by placing a sensor label on a dishwasher rack, and placing a butter-knife on top of the sensor label. Product packaging instructions indicated to attach the sensor label to the thickest clean dry dish.

Review of the dietary staff completed "Dish Machine Log" for November and December 2019, completed at each meal failed to reveal documentation of temperatures taken on:
11/06/19: dinner
11/07/19: dinner
11/08/19: dinner
11/11/19: dinner
11/12/19: breakfast, lunch, dinner
11/14/19: lunch, dinner
11/15/19: lunch, dinner
11/16/19: breakfast, lunch, dinner
11/17/19: breakfast, lunch, dinner
11/20/19: breakfast, lunch, dinner
11/22/19: breakfast, lunch, dinner
11/26/19: breakfast, lunch, dinner
11/28/19: dinner
11/29/19: breakfast, lunch, dinner
11/30/19: breakfast, lunch, dinner

A dietary staff completed dish machine log was not able to be provided for December 2019.

Review of the dietary staff completed "Third Sink Sanitizer PPM (parts per million) Log" for November and December 2019, completed at each meal failed to reveal documentation of sanitizer levels taken on:
11/17/19: dinner
11/18/19: breakfast, lunch, dinner
11/19/19: breakfast, lunch, dinner
11/20/19: breakfast, lunch, dinner
11/21/19: breakfast, lunch, dinner
11/22/19: breakfast, lunch, dinner
11/23/19: breakfast, lunch, dinner
11/26/19: breakfast, lunch, dinner
11/27/19: dinner
11/30/19: breakfast, lunch, dinner
12/11/19: dinner
12/12/19: breakfast, lunch, dinner
12/13/19: breakfast, lunch, dinner
12/14/19: breakfast, lunch, dinner
12/15/19: breakfast, lunch, dinner
12/16/19: breakfast, lunch, dinner
12/17/19: breakfast, lunch, dinner
12/18/19: breakfast, lunch, dinner
12/19/19: breakfast, lunch, dinner
12/20/19: breakfast, lunch, dinner
12/21/19: breakfast, lunch, dinner
12/22/19: breakfast, lunch, dinner
12/23/19: breakfast, lunch, dinner
12/24/19: breakfast, lunch, dinner
12/25/19: breakfast, lunch, dinner
12/26/19: breakfast, lunch, dinner
12/27/19: breakfast, lunch, dinner
12/28/19: breakfast, lunch, dinner
12/29/19: breakfast, lunch, dinner
12/30/19: breakfast, lunch, dinner
12/31/19: breakfast, lunch, dinner


During an interview on 1/4/20, at 10:39 a.m. Food Service Manager Employee E1 confirmed that the facility failed to dispose of expired food products, maintain equipment in a sanitary manner, and make certain that equipment was properly sanitized in the Main Kitchen which created the potential for cross contamination.

28 Pa Code: 211.6(c)Dietary services
Previously cited: 5/17/19, 6/15/18.

28 Pa Code: 211.6(d) Dietary services
Previously cited: 5/17/19.

28 Pa. Code: 207.2(a) Administrator's responsibility.
Previously cited: 5/17/19, 3/11/19.



 Plan of Correction - To be completed: 02/18/2020

- Working thermometers were replaced immediately following the surveyor observation.
- The test strips for testing the three compartment sink sanitizing levels, were found and used immediately following the surveyor observation and began being used properly
- All unlabeled/dated items in the kitchen areas were thrown out.
- All items in the dry storeroom including bulk food containers, as well as bulk food containers throughout the kitchen, will be labeled and dated appropriately.
- All items in the walk in refrigerator will be labeled and dated appropriately.
- Test strips and log were reviewed with staff to verify the final rinse temperature of the dish machine
- Dietary Manager and dietary staff will be re-educated by the Registered Dietitian or designee on the Food Storage, Labeling and dating of food, Dish machine speculations, use, and temperature checking, Ware Washing, Food temps, Logging of ppm for three compartment sink and Cleaning and sanitizing of equipment and work areas.
- NHA and Registered Dietician will audit kitchen procedures once weekly for 4 weeks.
- An audit will be completed twice weekly for two weeks and once weekly for a month by the food service manager or designee of the dry storage room and walk in refrigerators to ensure labeling and dating of materials
- An audit will be completed daily for two weeks and once weekly for a month by the food service manager or designee of all kitchen cleanliness
- An audit will be completed twice weekly for two weeks and once weekly for a month by the food service manager or designee of test strips being used for the three compartment sink as well as the dish machine temp log, and food temperature log.
o All audit results will be reviewed monthly by the QAPI committee for further suggestions and/or interventions


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