Nursing Investigation Results -

Pennsylvania Department of Health
EDGEHILL NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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EDGEHILL NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  47 surveys for this facility. Please select a date to view the survey results.

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EDGEHILL NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Special Monitoring survey completed on June 2, 2022, it was determined that Edgehill Nursing and Rehabilitation Center was not in compliance with the following Requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as it relates to the health portion of the survey process.


 Plan of Correction:


211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.
Observations:

Based on a review of nursing staffing hours, it was determined that the facility failed to provide the minimum number of general nursing care hours per patient (PPD) in a 24 hour period for four of 21 days reviewed. (September 3, 5, 2021 and January 1, 3, 2022)

Findings include:

Review of nursing staffing hours from September 2, 2021 through April 25, 2022 revealed that the facility failed to maintain a minimum of 2.7 hours of per resident in a 24 hour period on the following dates:

September 3, 2021 = 2.47
September 5, 2021 = 2.04
January 1, 2022 = 2.39
January 3, 2022 = 2.67






 Plan of Correction - To be completed: 06/29/2022

1. The facility is unable to retroactively correct staffing for the dates listed. The facility continues to strive to maintain staffing at or above the state minimum requirements despite industry wide staffing challenges.

2. NHA or designee will review nursing staffing hours for the last 90-days ensure the minimum staffing requirement has been maintained.

3. NHA, and/or DON, and/or ADON, and/or scheduler will continue to review projected staffing hours daily and coordinate coverage when staffing is expected to fall below the minimum requirement. The facility strives to meet the state minimum of staffing. The facility will continue to use agency staffing when needed to maintain the minimum staffing requirement. The facility will continue to actively recruit for open positions.

The facility will notify DOH if the minimum staffing requirement is not able to be met as required and will advise of actions to maintain quality. The facility will develop a contingency plan listing the additional steps to be taken when staffing may fall below the minimum requirement. The contingency plan will include managers/ancillary staff assisting with non-clinical tasks on the units such as passing meal trays, passing water, and answering call bells.


4. NHA or designee will complete PPD audits daily for 1 week, weekly for a month, and monthly for 3 months. Results will be analyzed by the NHA/designee to identify trends or patterns and reported at monthly Quality Assurance Performance Improvement Meeting for the next three months for further review and/or recommendations.

5. Date of completion: June 29th, 2022


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