Pennsylvania Department of Health
CLEPPER MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CLEPPER MANOR
Inspection Results For:

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CLEPPER MANOR - 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 Survey completed May 17, 2024, it was determined that Clepper Manor 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:

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

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(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations:

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to ensure that a PRN (as needed) anti-anxiety psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication had clinical rationale identified for the use beyond the limitation of 14 days for one of 11 residents (Resident R34).

Findings include:

A review of a facility policy entitled "Use of Psychotropic Medication" dated 2/21/24, stated "PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for PRN order."

Resident R34's clinical record revealed an admission date of 2/16/24, with diagnoses of encounter for palliative care (hospice care), severe protein-calorie malnutrition (inadequate intake of protein, calories, and other essential nutrients), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and anxiety.

Resident R34's clinical record revealed a physician order dated 2/17/24, for Trazadone (medication to treat depression by restoring the balance of natural chemicals in the brain) 100 milligram by mouth at hour of sleep (HS) PRN. The clinical record lacked evidence of clinical rationale for the use of Trazadone beyond 14 days.

During an interview on 5/17/24, at 10:35 a.m. the Director of Nursing confirmed there was no duration ordered by the physician for the extended time-period of Resident 34's PRN Trazadone usage beyond 14 days.

28 Pa. Code 211.10(c) Resident care policies

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

Plan of Correction - To be completed: 07/02/2024

Resident R34 now has a stop date for PRN trazodone.
Orders will be reviewed by the DON or designee to ensure any resident with a PRN psychotropic order had a 14 day stop date and review for continued use.
New medication orders will be reviewed during morning clinical meeting by the DON/ Designee. Any new PRN psychotropic orders for new and existing residents that do not have a stop date will have the order updated to include 14 day stop date.

DON/designee will educate licensed staff members on the appropriate process and procedure on following pharmacy recommendations for PRN psychotropic medications.

DON/designee will provide licensed prescribers the facility's policy entitled "Use of Psychotropic Medications" highlighting the limited duration for PRN psychotropic orders as well as the need for rationale and indication for an extension beyond the recommended fourteen days.

DON/designee will audit all pharmacy recommendations including physician follow-up and compliance with fourteen day stop date or rationale for use beyond fourteen days monthly times two months.

Results of the audits will be reviewed at the Quality Assurance Performance Improvement (QAPI) meetings to determine compliance.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Plan of Correction - To be completed: 06/21/2024

The facility will make its best effort to maintain the one nurse aide to every twelve residents for the day and afternoon shift. The facility will also make its best effort to maintain the one nurse aide to twenty residents on the night shift.

The Administrator or designee will have a staffing meeting each morning to ensure the proper staff to resident ratios meet shift requirements.

The Administrator will educate the scheduler on the requirements for the CNA ratios for each shift.

Administrator or his designee will continue to recruit potential employees by placing ads on Indeed and other recruiting mediums, networking within the community through Facebook and other social media.

Offering sign-on bonuses to potential employees.

Offering pick-up bonuses to staff that already work for the facility.

The facility will send employees interested in becoming a C.N.A. to Certified Nursing Assistant training to get their certificate to provide direct care.

Offer a referral bonus to employees that encourage candidates to apply.

The Facility will continue to utilize Staffing agencies to fill open shifts. All Shifts, Shift Med, and Shift Key.`

The Facility will utilize LPN's as certified nursing assistants when available.

The facility will increase recruiting efforts.

The facility will use the On-Shift program to make the schedule accessible to staff to see open shifts and pick them up.

The Administrator and his designee will monitor staffing 5 days a week for 4 weeks, reviewing the schedule for openings and placing staff where needed to ensure the proper PPD.

Staffing agencies will be utilized to staff the building on occurrence where the facility is unable to staff with own employees.

The Administrator and his designees will review the staffing concerns in Quarterly QAPI meetings.

The administrator or designee will review retention efforts, and to root cause any issues that present themselves to ensure proper staffi ng ratios are maintained.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on review of facility staffing information documents and staff interview, it was determined that the facility failed to ensure a minimum of one Licensed Practical Nurse (LPN) per 40 residents on the overnight shift, for three of 21 days reviewed for staffing ratio.

Findings include:

Review of facility staffing ratio information from 11/12/2023 through 11/18/2023, 4/1/2024 through 4/7/2024, and 5/9/2024 through 5/14/2024, revealed the following LPN staffing shortages for the overnight shift:

11/12/2023, facility census of 44 residents, 1.00 LPNs scheduled and 1.10 were required.
11/16/2023, facility census of 43 residents, 1.00 LPNs scheduled and 1.08 were required.
11/18/2023, facility census of 44 residents, 1.00 LPNs scheduled and 1.10 were required.

During an interview on 5/17/2024, at approximately 12:30 p.m. the Nursing Home Administrator confirmed that the facility failed to meet the minimum LPN ratio requirements on the above dates and shift.

Plan of Correction - To be completed: 06/21/2024

The facility will make its best effort to maintain the one LPN to every twenty-five residents for the day shift, the one LPN to thirty residents on evening shift, and the one LPN to forty residents on night shift.

The Administrator or designee will have a staffing meeting each morning to ensure the proper staff to resident ratios meet shift requirements.

The Administrator will educate the scheduler on the ratios for LPN's on each shift.

The Administrator or his designee will continue to recruit potential employees by placing ads on Indeed and other recruiting mediums, networking within the community through Facebook and other social media.

Offering sign-on bonuses to potential employees.

Offering pick-up bonuses to staff that already work for the facility.

Offer a referral bonus to employees that encourage candidates to apply.

The Facility will continue to utilize Staffing agencies to fill open shifts. All Shifts, Shift Med, and Shift Key.

The facility will increase recruiting efforts.

The facility will use the On-Shift program to make the schedule accessible to staff to see open shifts and pick them up.

The Administrator and his designees will monitor staffing 5 days a week for 4 weeks, reviewing the schedule for openings and placing staff where needed to ensure the proper PPD.

Staffing agencies will be utilized to staff the building on occurrence where the facility is unable to staff with own employees.

The Administrator and his designees will review the staffing concerns in Quarterly QAPI meetings.

The administrator and designees' will review retention efforts, and to root cause any issues that present themselves to ensure proper staffing ratios are maintained.

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Observations:

Based on review of the facility staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Registered Nurse (RN) per 250 residents on the overnight shift for one of 21 days reviewed (11/13/2023).

Findings include:

Review of facility staffing ratio information from 11/12/2023 through 11/18/2023, 4/1/2024 through 4/7/2024, and 5/9/2024 through 5/14/2024, revealed the following RN staffing shortages for the overnight shift:

11/13/2023census of 44 residents0.00 RNs scheduled and 1.00 was required.

During an interview on 5/17/2024, at approximately 12:30 p.m. the Nursing Home Administrator confirmed that the facility failed to meet the required ratios of one RN per 250 residents on the above date and shift.

Plan of Correction - To be completed: 06/21/2024

The facility will make its best effort to maintain the one RN to every 250 residents for the night shift.

The Administrator will educate the scheduler on the ratios for RN's on the night shift.

The Administrator or designee will have a staffing meeting each morning to ensure the proper staff to resident ratios meet shift requirements.

The Administrator or his designee will continue to recruit potential employees by placing ads on Indeed and other recruiting mediums, networking within the community through Facebook and other social media.

Offering sign-on bonuses to potential employees.

Offering pick-up bonuses to staff that already work for the facility.

Offer a referral bonus to employees that encourage candidates to apply.

The Facility will continue to utilize Staffing agencies to fill open shifts. All Shifts, Shift Med, and Shift Key.

The facility will increase recruiting efforts.

The facility will use the On-Shift program to make the schedule accessible to staff to see open shifts and pick them up.

The Administrator and his designees will monitor staffing 5 days a week for 4 weeks, reviewing the schedule for openings and placing staff where needed.

Staffing agencies will be utilized to staff the building on occurrence where the facility is unable to staff with own employees.

The Administrator and his designees will review the staffing concerns in Quarterly QAPI meetings.

The administrator and designees' will review retention efforts, and to root cause any issues that present themselves to ensure proper staffing ratios are maintained.

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