Nursing Investigation Results -

Pennsylvania Department of Health
QUALITY LIFE SERVICES - MERCER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
QUALITY LIFE SERVICES - MERCER
Inspection Results For:

There are  51 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.
QUALITY LIFE SERVICES - MERCER - 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 on October 7, 2021, it was determined that Quality Life Services - Mercer 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(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were performed during catheter care for one of 14 residents reviewed (Resident R91).

Findings include:

Review of the "Catheter: Care of Indwelling Urinary" policy, dated 1/28/21, identified for staff to use downward strokes from the pubic area to the rectal area and when cleaning the catheter tube, wash away from the insertion site.

Observation on 10/5/21, at 2:15 p.m. revealed that Nurse Aide (NA) Employee E2 identified that Resident R91's catheter was leaking and requested Licensed Practical Nurse (LPN) Employee E1 to check it. LPN Employee E1 noticed that the catheter tubing leading to the foley bag was disconnected. He/she connected the tubing without first cleansing the tubing with alcohol. During an interview on 10/5/21 at 2:20 p.m., LPN Employee E1 confirmed the above information.

Observation on 10/5/21, at 2:25 p.m. revealed that NA Employee E2 was performing catheter care on Resident R91 and did not wash from the pubic area to rectal area. In addition, he/she cleansed the catheter tube towards the pubic area instead of away from the pubic area. During an interview on 10/5/21, at 2:35 p.m., NA Employee E2 confirmed the above information.

During an interview on 10/6/21, at 8:30 a.m. the Director of Nursing confirmed that alcohol should have been used before connecting the catheter tubing and that catheter care included washing the pubic area and cleansing the catheter tube away from the pubic area.

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





 Plan of Correction - To be completed: 11/29/2021

Employee E1 and employee E2 were immediately educated on care of an indwelling catheter. Resident R91's catheter tubing and bag was changed on 10/5/21, cleansing catheter prior to application of new tubing and bag. No adverse affects to resident R91. Nursing staff to be educated by Director of Nursing or Designee on policy and procedure for care of an indwelling catheter. Audits on catheter care will be completed by Director of Nursing or Designee 3 times per week for 1 week, then weekly for 4 weeks. Results of audits will be reported at the monthly QAPI meeting.
483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ: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.
483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
Observations:


Based on observations and staff interview, it was determined that the facility failed to maintain equipment in proper condition to maintain a safe and sanitary environment for one of one hallways leading to the kitchen.

Findings include:

Observations on 10/4/21, at 8:51 a.m. in the short hallway leading into and out of the kitchen revealed that the windows were open and that the one window screen had approximately a one inch by one inch hole in it with the potential for bugs and flies to enter the hallway adjacent to the kitchen area. In addition, other window screens in this area had smaller open areas creating the potential to get larger and let bugs and flies into the kitchen area.

During an interview on 10/4/21, at 9:00 a.m. the Environmental Services Director confirmed the above information.

28 Pa. Code 207.2(a) Administrator's responsibility




 Plan of Correction - To be completed: 11/29/2021

Windows in short hallway leading to kitchen were immediately closed. Window screens were replaced on 10/7/21. Staff will be educated by Director of Nursing or designee to report any potential openings in screens to maintenance for repair. Audits will be completed by Director of Nursing or Designee weekly for 4 weeks to insure there are no openings/holes in screens in short hallway leading to kitchen. Results of audits will be reviewed at the monthly QAPI meeting.



483.80(b)(1)-(4)(c) REQUIREMENT Infection Preventionist Qualifications/Role: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(b) Infection preventionist
The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must:

483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;

483.80(b)(2) Be qualified by education, training, experience or certification;

483.80(b)(3) Work at least part-time at the facility; and

483.80(b)(4) Have completed specialized training in infection prevention and control.

483.80 (c) IP participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.
Observations:


Based on review of facility records and staff interviews, it was determined that the facility failed to ensure the designated Infection Preventionist (IP) was qualified with specialized training in infection prevention and control.

Findings include:

During the entrance conference interview on 10/4/21, the Nursing Home Administrator (NHA) revealed that the facility past Director of Nursing (DON) was the designated IP and since his/her departure from the facility, the corporate nurse had been overseeing the infection control program and duties. Review of facility records indicated that the DON who was the designated IP left the facility on 7/30/21.

During an interview on 10/7/21, at 8:33 a.m. the NHA confirmed that the corporate nurse who had been overseeing the infection control program and duties for the past 66 days had not yet completed the required specialized training / education.

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

28 Pa. Code 211.10(d) Resident care policies

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









 Plan of Correction - To be completed: 12/06/2021

Infection Preventionist identified within facility nursing staff. Specialized training on infection prevention and control will be provided to qualified individual starting November 2021 and projected to be completed 12/6/21. Infection preventionist will participate on Quality Assessment Process Improvement committee and will report to the committee on IPCP on a regular basis. Education will be provided to Director of Nursing, Infection Preventionist and Administrator on requirement for Infection Preventionist Qualifications. Audits will be completed by Director of Nursing or Designee weekly for 4 weeks to ensure timely progress in training, education and certification. Results of audits will be reviewed at the monthly QAPI meeting.
483.20(g) REQUIREMENT Accuracy of Assessments:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on review of clinical records and Minimum Data Set (MDS - periodic assessment of resident care needs) and staff interview, it was determined that the facility failed to accurately assess one of 14 residents reviewed (Resident R1).

Findings include:

Review of Resident R1's clinical record revealed an admission date of 6/26/20, with diagnoses that included dementia with behavioral disturbances (affects memory, thinking, and social abilities severely enough to interfere with daily life, with agitation symptoms), delusions (false idea or belief), and high blood pressure. A progress note dated 6/9/21, from hospice services revealed that Resident R1 had been admitted into their hospice program on that date.

Review of Resident R1's quarterly MDS dated 7/7/21, revealed that Section O-00100 did not identify that hospice care was selected.

During an interview on 10/6/21, at 9:15 a.m. the Registered Nurse Assessment Coordinator confirmed that Resident R1's quarterly MDS was not coded accurately to reflect hospice services provided.

28 Pa. Code 211.12(d)(5) Nursing services





 Plan of Correction - To be completed: 11/29/2021

I hereby acknowledge the CMS 2567-A, issued to QUALITY LIFE SERVICES - MERCER for the survey ending 10/07/2021, AND attest that all deficiencies listed on the form will be corrected in a timely manner.
Quality Life Services Mercer has adopted internal processes as part of our on-going commitment to provide quality care to the residents we serve. The attached information contains Quality Life Services Mercer's Plan of Correction which we are submitting in response to specific deficiencies identified by the Pennsylvania Department of Health and is required for purposes of our facility's licensure and certification. The information and responses contained in our Plan of Correction are consistent with our own quality improvement efforts and should not be construed as an admission of or agreement with the deficiencies cited in the Department's findings. This Plan of Correction is not an admission of wrongdoing on the part of Quality Life Services Mercer.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port