Nursing Investigation Results -

Pennsylvania Department of Health
CHERRY TREE NURSING CENTER
Patient Care Inspection Results

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CHERRY TREE NURSING CENTER
Inspection Results For:

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CHERRY TREE NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and an Abbreviated Survey in response to three complaints completed on September 9, 2019, it was determined that Cherry Tree Nursing Center 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:


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is the most serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified. This deficiency was not found to be throughout this facility.
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, facility document review and staff interviews, it was determined that the facility failed to consistently maintain an infection prevention and control program, which ensured proper cleaning and disinfecting of glucometers (a device used to test the amount of sugar in a person's blood) to prevent the potential for cross-contamination. This deficient practice affected 14 of 19 residents who required glucometer checks (Residents R1, R4, R7, R13, R15, R41, R60, R66, R68, R70, R71, R73, R77, and R79) on three of four nursing units (Two North, Two South, and Three North), thereby; placing them at risk for potential infection and the facility in an Immediate Jeopardy situation.

Findings Include:

Review of the facility policy titled "Blood Sampling - Capillary (Finger Sticks)" dated 5/4/19, indicated that staff should "clean blood glucose meter off with alcohol pledget" (a small flat absorbent pad).

Review of the guidance released by the U.S. Food and Drug Administration on 8/23/10, indicated that 70% ethanol solutions are not effective against viral bloodborne pathogens.

Review of the Centers for Disease Control and Prevention's document titled "Infection Prevention during Blood Glucose Monitoring and Insulin Administration" last reviewed 3/2/11, indicated that if blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents.

Review of the glucometer manufacturer's recommendation provided by the facility revealed under "Cleaning and Disinfecting Procedures for the Meter" indicated the meter must be disinfected between patient use by wiping it with an EPA (Environmental Protection Agency) approved disinfecting wipe.

During observation of a blood sugar check on 9/5/19, at 9:02 a.m. Licensed Practical Nurse Employee E2 cleaned the glucometer after use with a 70% isopropyl alcohol pad. Observation of the 2 North medication cart at this time did not reveal any germicidal wipes.

During an interview on 9/5/19, at 9:30 a.m. Registered Nurse Employee E3 stated that she used alcohol pads to clean the glucometer she used. Observation of the 2 South medication cart at this time did not reveal any germicidal wipes.

During an observation of the 3 North medication cart on 9/5/19, at 11:02 a.m. did not reveal any germicidal wipes.

On 9/5/19, at 2:42 p.m. the Director of Nursing was informed of Immediate Jeopardy at the facility and a request for a written Correction Action Plan. The Correction Action Plan was accepted on 9/5/19, at 6:30 p.m. and included the following:
1. Outgoing and incoming licensed staff were re-in serviced on proper cleaning and disinfection and storage of glucose meters per manufacture guidelines.
2. Outgoing and incoming licensed staff will be re-in serviced on proper cleaning and disinfection and storage of glucose meters per manufacture guidelines.
3. Identified nurses will be given one-on-one training prior to next scheduled shift.
4. Policy of glucose cleaning, disinfectant, and storage will be reviewed and updated according to manufacturer ' s recommendations by the DON designee.
5. Glucose meter audits will be performed with licensed staff on the proper cleaning by the QA nurse or the designee, Q shifts x 2 weeks; 2-day x 4 weeks; Q week x 4 weeks; Q month x 4 months.
6. Results of QA audit will be reported to the QA committee monthly x 6 months.
7. Med cart compartment housing the glucose monitors will be cleaned by the 11p-7a shift nightly.
8. Sani wipes will be stored on the med carts. Nursing will notify central supply when needed to be replenished.

On 9/6/19, at 7:15 a.m. the Immediate Correction Action Plan was reviewed, observations and interviews were conducted to assure implementation.

On 9/6/19, at 7:40 a.m. Night Shift Supervisor Registered Nurse Employee E4 was interviewed, and confirmed that all night shift licensed staff had been re-educated in glucometer cleaning procedures prior to beginning their shift the evening prior, and all the day shift licensed staff had been re-educated in glucometer cleaning procedures prior to beginning their shift, including the two identified nurses received individual education.

On 9/6/19, at 8:20 a.m. the medication carts were observed, with four of four clean, and the appropriate germicidal wipes were available in the carts.

On 9/6/19, at 9:00 a.m. the education provided to staff on cleaning and disinfection of the glucometer, manufacturer's guidelines, and storage was reviewed, with two staff meetings completed on 9/5/19, educating nine of nineteen licensed staff. Three glucometer audits were completed, including one with the identified nurses. The plan for the education of staff on scheduled days off or vacation prior to their returning to work was reviewed.

On 9/6/19, at 10:55 a.m. the Nursing Home Administrator was notified that the Immediate Jeopardy was lifted.

The facility failed to consistently maintain an infection prevention and control program, which ensured proper cleaning and disinfecting of glucometers (a device used to test the amount of sugar in a person's blood) to prevent the potential for cross-contamination. This deficient practice affected 14 of 19 residents who required glucometer checks (Residents R1, R4, R7, R13, R15, R41, R60, R66, R68, R70, R71, R73, R77, and R79) on three of four nursing units (Two North, Two South, and Three North) placing them at risk for potential infection and the facility in an Immediate Jeopardy situation.

42 CFR 483.80(a)(1)(4)(f) Infection Prevention & Control.
Previously cited 10/18/18.

28 Pa. Code Responsibility of licensee.
Previously cited 10/18/18.

28 Pa. Code Management.
Previously cited 10/18/18.

28 Pa. Code Management.

28 Pa. Code Staff development.
Previously cited 10/18/18.

28 Pa. Code Resident rights.

28 Pa. Code Resident care policies.
Previously cited 10/18/18.

28 Pa. Code Nursing services.
Previously cited 10/18/18.





 Plan of Correction - To be completed: 10/07/2019

1. Residents receiving blood sugar testing will be provided their own individual glucometers for testing and education.
2. Upon new admission or new order for blood sugar testing of resident, a glucometer will be provided for that individual residents use.
3. The licensed nursing staff were re-educated on proper cleaning, disinfection, and storage of glucose meters per the manufacturer guidelines.
4. Nurse identified in deficient practice was re-educated in proper cleaning, disinfection, and storage of glucose meters per the manufacturer guidelines on a 1:1 basis with the DON.
5. A copy of glucose meter instruction booklet with recommendations for cleaning/disinfecting of glucose meters has been placed in each narcotic book on the medication carts.
6. Policy for cleaning/disinfecting of glucose meters has been reviewed and updated with appropriate instructions to manufacturer's recommendations.
7. Nursing staff in serviced on the revised policy for cleaning/disinfecting glucose meters.
8. Sani wipes will be stored on med carts/supply room .
9. QA audit tool devised for monitoring glucose testing and cleaning of glucose meters.
10. Nursing will notify central supply when sani wipes need replenished
11. Directed in services will be provided to nursing staff by Linda Lewis of Lewis Litigation Support and Clinical Consulting, LLC on October 2, 2019 at Cherry Tree Nursing Center.
12. Med cart compartment housing the glucose meters will be cleaned by the 11-7 shift.
13. Audit tool devised to monitor cleaning and storage of compartment and sani wipes on med carts.
14. QA nurse will audit med cart compartment cleaning and sani wipe presence on med carts every night x 4 months
15. The QA nurse/designee will complete random audits with 2 licensed staff on cleaning/disinfecting of glucose meters every shift x 2 weeks, then every day x 4 weeks, then every week x 4 weeks, then every month x 4 months.
16. Results of audit will be reported in QA minutes monthly x 4 months.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:
Based on review of facility policy and clinical records and staff interviews, it was determined that the facility failed to develop a comprehensive care plan for two of 18 residents (Resident R26 and R34).

Findings include:

Review of the facility policy "Care Planning" dated 5/4/19, indicated that the facility would develop and implement a comprehensive, person-centered care plan for each resident.

The clinical record indicated that Resident R26 was admitted to the facility on 9/20/13, with diagnoses that included Parkinson's disease (a chronic and progressive movement disorder), convulsions and major depressive disorder.

A summary of physician orders dated 9/9/19, indicated that Resident R26 was to take Divalproex (a medication used for seizures and mood disorders) twice daily to treat depression.

Review of Resident R26's plan of care updated 7/24/19, indicated that the resident was not currently on any psychotropic medications (medication used for psychiatric conditions).

During an interview on 9/9/19, the Director of Nursing (DON) confirmed that the facility failed to develop an accurate plan of care for Resident R26.

The clinical record indicated that Resident R34 was admitted to the facility on 6/7/19, with diagnoses including Huntington's Disease (a condition that leads to progressive degeneration of nerve cells in the brain)., major depressive disorder, and dysphagia.

During the survey entrance conference on 9/3/19, the Nursing Home Administrator and Director of Nursing confirmed that Resident R34 was the only smoker in the building, and that he currently utilizes electronic cigarettes.

Review of Resident R34's plan of care updated 6/8/19, did not reveal a plan of care for smoking or electronic cigarette use.

During an interview on 9/9/19, at 1:40 p.m. the Director of Nursing confirmed that the facility failed to develop an accurate plan of care for Resident R34.


28 Pa. Code: 211.12 (d)(1)(5) Nursing services.
Previously cited 10/18/19.


 Plan of Correction - To be completed: 10/07/2019

Resident R26 plan of care was reviewed and amended to address psychotropic medication administration for depression and seizure disorder.
Resident R34 individualized smoking care plan was developed incorporating interventions already utilized in his N37 care plan.
Other residents in facility who utilized medications classified as psychotropic were reviewed and no other issues were found.
On admission if a resident is identified as a smoker an individualized smoking care plan will be developed.
An audit tool was be developed to monitor orders for residents psychotropic medication and/or residents who prefer to smoke.
An audit tool was be developed to monitor orders for residents psychotropic medication. Social service/designee will audit 5 residents with psychotropic medication orders and care plans daily x2 weeks, weekly x4 weeks, and monthly x2 months.
Results of the audit will be reported monthly in QA by services/designee x4 months.
Audit tool for residents who smoke devised.
Social service /designee will audit 1 resident a day who smokes for orders and care plans for 2weeks, weekly x4 weeks, and monthly x 2 months.
Results of audit will be reported in QA meetings monthly by social service x 4 months.
483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to issue the Notice of Medicare Noncoverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN), used to inform the resident of the right to appeal or of specific services that may not be covered and of the resident's potential liability for payment of non covered service for three of three residents (Resident CR1, R42, and R68).

Information provided by the facility on the Entrance Conference Worksheet for Beneficiary Notice indicated that Resident CR1 was discharged home from the facility on 6/29/19.

A review of the NOMNC for Resident CR1 revealed that the Medicare provider probably would not pay for services after 6/28/19, and the resident had the right to appeal by calling the toll-free phone number before noon, the day prior to 6/28/19. However, the resident signature and date indicated the notice was provided on 6/28/19, which was after the deadline to appeal the decision to end payment for services.

A review of the Admission Face sheet indicated Resident R42 was admitted to the facility on 7/8/19, and remained at the facility.

A review of the the NOMNC for Resident R42 revealed that services for Medicare non coverage would end on 8/11/19. Review of the facility completed Beneficiary Protection Notification Review indicated that Resident R42 was not provided a SNF-ABN, Form CMS-1055 (a form notifying the resident of costs that may be incurred for services no longer provided by Medicare payment).

A review of the Admission Face sheet indicated Resident R68 was admitted to the facility on 6/12/19, and remained at the facility.

A review of the the NOMNC for Resident R68 revealed that services for Medicare non coverage would end on 8/9/19. Review of the facility completed Beneficiary Protection Notification Review indicated that Resident R68 was not provided a SNF-ABN, Form CMS-1055.

During an interview on 9/6/19, at 10:36 a.m. Social Worker Employee E1 confirmed the facility failed to issue the NOMNC for Resident CR1 before noon of the effective date Medicare would no longer pay for current services and not in time to appeal and further confirmed that the facility failed to provide Residents R42 and R68 the SNF-ABN Form to inform the residents of costs that may be incurred for services no longer provided by Medicare payment.

28 Pa. Code: 201.18(b)(2) Management.

28 Pa. Code: 201.18(e)(1) Management
Previously cited 10/18/18.

28 Pa. Code: 201.29(a) Resident rights.
Previously cited 10/18/18.


 Plan of Correction - To be completed: 10/07/2019

Resident CR1 and R42 are no longer at facility.
Resident R68 remains at facility and was provided a SNF/ABN-CMS 1055 form along with education.

Social Workers in facility were reeducated and re in serviced on completion of NOMNC and SNF ABN form/CMS 1055 and on the timeliness of completing and providing residents with these forms.
Other residents in facility on Medicare A services were reviewed and no other issues were found.
During Medicare meeting residents identifies as being "cut" from Medicare A services will be listed on a weekly audit tool by social services.
An audit took has been devised to track Medicare A residents with date of discharge from Medicare A services, date of NOMNC, date of issue of SNF/ABN/CMS 1055 form.
BOM/designee will perform audits weekly of Medicare A cut services x2 months
Results of audit will be reported in monthly QA x2 months by BOM/designee


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