Pennsylvania Department of Health
FOULKEWAYS AT GWYNEDD
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
FOULKEWAYS AT GWYNEDD
Inspection Results For:

There are  35 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.
FOULKEWAYS AT GWYNEDD - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Licensure survey and a Civil Rights Compliance survey completed on December 7, 2023, it was determined that Foulkeways at Gwynedd was not in compliance with the following Requirements the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.



 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) 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 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.
§483.60(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 review of facility policy, observations, and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings include:

Review of facility policy titled, "Food and Supply Storage" dated January 2018, indicated that "All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Food past the " use by " , " sell by " , " best by " or " enjoy by " date should be discarded. Cover label and date unused portions and open packages.

An initial tour of the Food Service Department conducted on December 4, 2023 at 12:03 p.m., with Food Service Manager, revealed the following:

Observations of refrigerator located in the kitchen revealed the following items did not have a received and or use by date: egg salads, vegetables, and approximately 5 bags of boiled eggs.

Review of " House Equipment Temps " , daily temperature log for October 2023 revealed that refrigerator, freezer and dish machine temperature for morning and evening shift was not recorded from October 1 to October 18, 21, 22, 27 and 31. No evening shift temperature was recorded for the whole month.

Review of " House Equipment Temps " , daily temperature log for November 2023 revealed that refrigerator, freezer and dish machine temperature for morning and evening shift was not recorded for November 4, 5, 10, 11, 14, 18, 19, 24, 28. No evening shift temperature was recorded for the whole month.

Review of " House Equipment Temps " , daily temperature log for December 2023 revealed that refrigerator, freezer and dish machine temperature for morning and evening shift was not recorded from December 2 and 3 No evening shift temperature was recorded from December 1 to 3.

Observations and the temperature log missing information were confirmed by Food Service Manager, along the duration of the tour of the dietary department.


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

28 Pa. Code 211.6 (f) Dietary Services








 Plan of Correction - To be completed: 01/19/2024

- Re-education will be provided to all Gwynedd and Abington House Dining Service staff and cooks on policy for labeling food stored for use.
- All food items leftover from meal service will be labeled with the date and the discard date.
- All stored food items are dated with the 'use by' date and discarded at the end of the day of the use by date.
- The Director of Dining Services or designee will audit daily the compliance of refrigerated food storage procedures including leftover foods labeling for a period of 3 weeks; then 5 times a week for a period of a month; then 3 times per week for 3 months to ensure compliance.
- Director of Dining Services or designee will report findings to the QAPI meeting for review.

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.
483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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.
§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).
Observations:

Based on the review of clinical records, facility policies and interview with the staff, it was determined that the facility failed to notify the physician of a resident's change in condition/status in a timely manner. (Resident R1)
Finding Include
Review of facility policy " Attending Physician/Nurse Practitioner " dated July 26, 2019, indicated that " Respond to issues requiring a physician's expertise, including the Resident's current condition, the status of any acute episodes of illness since the last visit , test results, other actual or high-risk potential medical problems that are affecting the individual's functional, physical, or cognitive status, and staff, Resident, or family questions regarding the individual's care and treatments; Perform accurate, timely, relevant medical assessments; Respond in an appropriate time frame to emergency and routine notification, to enable the facility to meet its clinical and regulatory obligation; "
According to CDC (The Centers for Disease Control and Prevention- It is a United States federal agency under the Department of Health and Human Services) guidelines revealed that the normal respiratory rate for an adult ages above 18 was 12-20 respirations per minute.
Review of fall investigation report of Resident R1 dated November 28, 2023 revealed that the nursing assistant called the nurse after she observed resident on the floor. Resident was lying prone on the floor in her room between recliner and bed. Resident stated she was trying to go to her bed. Resident was noted with 2cm x 2 cm abrasion on side of the forehead. Approximately 1 cm round abrasion noted to the bridge of the nose. 0.5 cm superficial opening to the left side of the cheek surrounded by 2cm of redness. Resident also had red areas on her bilateral knees and a superficial abrasion on the lateral right knee measured approximately 0.5 cm. The respiration documented at the time of the fall was 32 respirations per minute.
Review of a neurological assessment sheet dated November 28, 2023 revealed that the resident's respiration after the fall was 32 respirations per minute. The second reading was documented as 28 respirations per minute.
Review of nursing progress note dated November 28, 2023, revealed that the nurse practitioner's was called and message left on her answering machine. There was no evidence that the increased respiratory rate was notified to the physician or nurse practitioner. Further review of the progress revealed no documented evidence that the physician or nurse practitioner responded to nurse's message or nurse attempted to reach out to the physician or other practitioners.
Further review of the clinical record revealed no evidence that the physician or nurse practitioner assessed the resident after she was noted with injury after the fall and increased respiratory rate. Staff did not notify the physician or the nurse practitioner in a timely manner.
Interview with the Director of Nursing, Employee E2, on November 6, 2023, at 2:20 p.m. confirmed that the staff should reach out to the physician for residents who sustain falls with injury and with abnormal vital signs timely. Employee E2 also confirmed that the staff did not notify the physician appropriately after Resident R1 sustained fall with injury and noted with increased respiratory rate.
PA Code: 211.10(c) Resident care policies.



 Plan of Correction - To be completed: 02/05/2024

1) Re-education will be provided to all professional nurses on timely notification of PCP/NP following a change in resident condition/status.
2) Re-education will be provided to all professional nurses on conducting a neurological assessment and the process to follow if vital signs are abnormal or outside of the prescribed guidelines.
3) DON or designee will audit all PEER events in which a change in condition occurs: daily for a period of 3 weeks; then 5 times a week for a period of a month, then 3 times per week for 3 months to ensure that the Physician/Nurse Practitioner was notified timely.
4) DON or designee will audit all neurological assessment sheets: daily for a period of 3 weeks; then 5 times a week for a period of a month, then 3 times per week for 3 months to ensure they are completed and followed up on timely with the PCP/NP.
5) Results of the audits will be taken to QAPI meeting for review.

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.
483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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.
§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on observations, review of clinical record and facility policy,and interviews with staff it was determined that the facility failed to administer oxygen as ordered by the physician for one of 37 residents reviewed. (Resident R2)

Finding Include:

Review of facility policy "Oxygen Administration System" dated March 2012 revealed that "Oxygen therapy must be prescribed by the resident ' s physician, not the respiratory vendor. The physician is responsible for identifying the type of therapy, the rate, based on ABG ' s and equipment needed by the patient."

Observation of Resident R2 on November 4, 2023, at 11:46 a.m. revealed that the resident was receiving oxygen via nasal cannula from an oxygen concentrator (machine). The oxygen was set at 3.5 L/min.

Review of physician orders for Resident R2 dated November 17, 2023, revealed an order to administer oxygen at 2L/min via nasal canula as needed for pulse ox (the saturation of oxygen carried in red blood cells) less than 90% "Oxygen at 3 liters /min via nasal cannula continuously every shift".

Review of vital signs record for Resident R2 from November 26, 2023, to December 5, 2023, revealed that the resident was administered oxygen at 3 liters/min on November 26, 27, December 2 3, 4 and 5, 2023. The resident was administered oxygen at 2.5 liters/min on November 30 and December 3, 2023. There was no documentation of 3.5 liters/min as observed on December 4, 2023

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

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




 Plan of Correction - To be completed: 02/05/2024

1) Oxygen order was rewritten for resident R2 by the Nurse Practitioner so as to provide a range for nurses to be able to adjust for oxygen liter flow based on oxygen saturation levels.
2) Re-education will be provided to all professional nurses that an order is required to administer and adjust oxygen liter flow.
3) Re-education will be provided to all professional nurses on how to monitor oxygen levels, report abnormal levels, titrate oxygen liter flow based on oxygen levels and document these findings accurately.
4) DON or designee will audit all vital signs records: daily for a period of 3 weeks; then 5 times a week for a period of a month, then 3 times per week for 3 months to ensure that they are completed accurately and follow prescribed orders.
5) Results of the audits will be taken to QAPI meeting for review.

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.
483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
Observations:

Based on the review of Quality Improvement Program (QUAPI) plan, facility documentation, and interview with staff, it was determined that the facility failed to demonstrate and maintain an effective Quality Improvement Program with systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events and performance indicators.

Findings include:

Review of facility policy "Quality Assurance/Quality (QAQI) and Improvement Program", dated October 15, 2020 revealed, " Foulkeways has maintained a comprehensive quality improvement program consistent with its own standards for excellence as well as with those of regulatory and industry forces. The goals of the program include:
To objectively monitor and systematically evaluate the appropriateness and quality of care provided;
To provide a mechanism whereby problems related to direct or indirect resident care can be identified and resolved proactively through a multidisciplinary approach;
To delineate standards of practice and/or service for individual departments;
To evaluate the results of action taken by individual departments to minimize duplication of effort and to maximize efficient use of Foulkeways resources; and
To centralize the quality assessment activities of individual departments and committees into comprehensive program.
Foulkeways' Board of Directors maintains ultimate responsibility for the assurance of the quality of resident care. The CEO, as the official representative of the Board, assumes responsibility for the program, and for assuring the Board that the quality of resident care is the highest achievable and that Foulkeways remains in compliance with applicable federal, state and local regulations.
The CEO, in turn, has delegated the responsibility for monitoring of care, standard development and implementation of corrective actions to the Quality Improvement Committee, of which the Director of Health Services is the designated chairperson. The Quality Improvement Committee chair functions as coordinator of all quality assessment and management activities among departments and committees, and serves as a resource in the development of standards and in the implementation of monitoring mechanisms.
Each department that has an impact on resident care is represented on the Committee.
Standing committee members include:
Director of Health Services, Chair;
Medical Director;
Risk Manager
Director of Nursing,
Director of Human Resources;
Dietitian;
The quality assessment/performance improvement plan occurs as part of a continuous cycle, which encompasses four critical phases:
1. Assessment & Measurement which includes
-Careful analysis of the processes and factors which contribute to the outcomes
-Measurements of specific components of the process (time, resources, critical path components)
-Identifying needed improvements
-Developing a complete understanding of the way things work
2. Planning & Design which includes:
-Creating new processes, retooling current processes or a combination of both
-Developing detailed plans of how to implement new designs
-Identifying actions to attain needed improvements
3. Implementation & Execution of the Plan which includes:
-Making new and redesigned processes operational through a series of well-defined steps
-Implementation of the interventions identified in the plan
4. Evaluation & Monitoring which includes:
-Review of clinical records
-Evaluation of outcomes
-Tracking of indicators with defined parameters of acceptability, by comparing performance to that of other institutions and/or by surveying customers with respect to the service and outcomes
-Recording the success or failure of the improvement effort
-Continuing to monitor to ensure that the improvement is maintained and additional improvement is undertaken when appropriate
Quality Assessment Committee
Assessment Committee which meets at least two (2) times per year.
The Committee will meet at an appointed time to review and/or act on the reports and activities of the individual departments and committees as determined by the Chair of the QAQI committee. Special meetings may be called at the request of any committee member.
Each department head and committee chair will be responsible for designating one or more persons within the department or committee to function as a quality improvement subcommittee for monitoring of the aspects of resident care for which they are responsible.
The following committee functions will be incorporated into the function of the Quality Improvement Committee:
a) Infection Control Committee
b) Pharmacy and Therapeutics Review
c) Safety Committee
Important aspects of resident care triggered by quality indicator reports and
assessment of resident satisfaction will be monitored on an ongoing basis.
Additionally', for Abington House, the following will be annually reviewed and evaluated:
a Reportable incident and condition reporting procedures
b) Complaint procedures
C) Staff training
d) Licensing violations and plans of correction, if applicable
Actual or potential problems are dealt with by the Quality Assessment Committee to propose recommended actions and/or Performance Improvement studies in order to ascertain if a quality concern actually exists. Criteria for PI Projects are that the project:
-Is in keeping with the mission, vision, values, and goals of the agency;
-Affects a large percentage of individuals for whom care is provided;
-Places individuals at risk for serious consequences or substantial loss of benefit if not provided correctly;
-High volume, high risk, and problem prone for Residents, volunteers or staff, or;
-Profoundly influences Resident outcomes
The results of reviews/audits are recorded and any problems/recommendations are reported to the Quality Assessment Committee and the Board of Directors
Performance Improvement Teams
Based on the outcomes measured through the programs described, the Quality Assessment Committee will focus on areas that need improvement. The Committee will then form a Performance Improvement Team to focus on any specific area of need, as needed. The chair of the performance improvement team is appointed by the Quality Assessment Committee and they select a team to work on the issue. Each performance improvement team is charged with a task and their focus is to improve the organizational performance in the assigned task area. "
A review of facility QUAPI program review was conducted with the Quality Assurance Coordinator on December 6, 2023, at 12:08 p.m. which revealed that the facility's QUAPI projects dated July 13, 2023, included no audits or data related to any of the performance indicators, improvement activities or evaluation of outcomes as outlined in the facility QUAPI program.

The facility's QUAPI projects dated August 3, 2023, included performance audits and data related to HIPAA, N-95 fit testing, COVID-19.

The facility's QUAPI projects dated October 19, 2023, included performance audits and data related to COVID-19 clinic, language line, renovation, flu vaccination and facility assessment. Further review of the October 2023 QUAPI program revealed that all of the August QUAPI projects were sustained.

The facility's QUAPI projects dated November 16, 2023, included performance audits and data included falls, COVID 19 vaccination update, relias (Education), phone update, massage/spa. Further review of the November 2023 QUAPI program revealed that all of the August and October QUAPI projects were sustained.

Review of facility QUAPI program and policy revealed that the facility did not maintain and sustain an effective Quality Improvement Program with systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events and performance indicators.

Interview with Quality Assurance Coordinator, on December 7, 2023, at 12:50 p.m. stated she was not aware of any previous QUAPI program and confirmed that the facility did not sustain QUAPI projects from one month to the other month without documented improvement or rationale.

28 Pa. Code 201.14(a) Responsibility of licensee

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












 Plan of Correction - To be completed: 02/05/2024

The facility will maintain an effective QAPI program with systems and reports demonstrating systematic identification, reporting, investigating, analysis and prevention of adverse events and performance indicators as evidence by sign in sheets with all required committee members; in addition, conduct meetings at least quarterly, demonstrate sustainability of an effective QAPI program as indicated by the following: maintain supporting documentation, regularly review and analyze data, audits, investigations, and other tracking tools which track and trend facility occurrences. And through QAPI initiatives, demonstrate corrective action and effective implementation.

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.
483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee: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.
§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist 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 documents, facility policy review, and staff interview, it was determined that the facility failed to ensure that all required committee members attended quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for four of six months of QAPI reviewed (June 2023- November 2023).

Findings include:
Review of facility policy "Quality Assurance/Quality (QAQI) and Improvement Program", dated October 15, 2020, revealed, " Foulkeways has maintained a comprehensive quality improvement program consistent with its own standards for excellence as well as with those of regulatory and industry forces.
The CEO, in turn, has delegated the responsibility for monitoring of care, standard development and implementation of corrective actions to the Quality Improvement Committee, of which the Director of Health Services is the designated chairperson. The Quality Improvement Committee chair functions as coordinator of all quality assessment and management activities among departments and committees, and serves as a resource in the development of standards and in the implementation of monitoring mechanisms.
Each department that has an impact on resident care is represented on the Committee.
Standing committee members include:
Director of Health Services, Chair;
Medical Director;
Risk Manager
Director of Nursing,
Director of Human Resources;
Dietitian;
A review of Quality Assurance/Performance Improvement (QAPI) Committee meeting sign-in sheets for the period of June 2023 through November 2023, revealed that the Medical Director was not in attendance for the July, August, October and November QAPI meeting. No QUAPI data available for June and September.

During an interview on December 7, 2023, at 12:08 p.m., the QAPI coordinator confirmed that the Medical Director was not in attendance for QUAPI meetings at least Quarterly.

28 Pa. Code 201.18(e)(1)(2)(3) Management





 Plan of Correction - To be completed: 02/05/2024

The Administrator or designee will ensure the Medical Director and all required committee members attends each QAPI meeting at least quarterly. Sign in sheets will be audited to ensure all committee members attend. The findings of the audits will be reported during the Quality Assurance/Performance Improvement Committee meetings for 6 months.

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.
§ 201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on staff interviews and review of facility infection control documentations, it was determined that the facility failed to ensure compliance with the requirements of the "Medical Care Availability And Reduction Of Error (Mccare) Act - Reduction And Prevention Of Health Care-Associated Infection And Long-Term Care Nursing Facilities Act Of Jul. 20, 2007, P.L. 331, No. 52 " .

Findings include:

The Act 52, "Medical Care Availability And Reduction Of Error (Mccare) Act - Reduction And Prevention Of Health Care-Associated Infection And Long-Term Care Nursing Facilities Act Of Jul. 20, 2007 ", indicated that a health care facility should develop and implement an internal infection control plan that should be established for the purpose of improving the health and safety of residents and health care workers and should include a multidisciplinary committee including a representative from each of the following, if applicable to the specific health care facility:

(i) Medical staff that could include the chief medical officer or the nursing home medical director
(ii) Administration representatives that could include the chief executive officer, the chief financial officer, or the nursing home administrator
(iii) Laboratory personnel
(iv) Nursing staff that could include a director of nursing or a nursing supervisor
(v) Pharmacy staff that could include the chief of pharmacy
(vi) Physical plant personnel
(vii) A patient safety officer
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility.

Review of the monthly attendance sheets for the Infection Control Committee dated June 2023 through November 2023 revealed that the medical director and a community member was not included in the committee.

During an interview on November 6, 2023 at 12:00 p.m.. Employee 2, Director of Nursing, confirmed that the Infection Control Committee did not include a community representative and medical director as required in accordance with Act 52.




 Plan of Correction - To be completed: 02/05/2024

The Administrator or designee will ensure the Medical Director, community representative, and all required committee members attends each Infection Control meeting as required in accordance with Act 52. Sign in sheets will be audited to ensure all committee members attend. The findings of the audits will be reported to the Quality Assurance/Performance Improvement Committee for 6 months.

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.
§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(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.

Observations:

Based on a review of nursing staffing hours and staff interview, it was determined that the facility did not ensure a minimum of one nurse aide per 20 residents during the night shift on two of 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following staff scheduled for the resident census:

Night shift (requires one NA per 20 residents)
September 7, 2023, two NAs, with a census of 41 residents, required three NAs.
December 2, 2023, two NAs, with a census of 41 residents, required three NAs.

Interview with the Nursing Home Administrator on December 6, 2023, at 1:30 p.m. confirmed that the above staffing levels did not meet the required minimums.



 Plan of Correction - To be completed: 02/05/2024

The nursing staff scheduler will schedule to meet the state mandates. Daily staffing levels will be audited daily by Director of Nursing/designee for a period of two months, to ensure that staffing levels provided are at or above the state and federal requirements that went into effect July 1, 2023.

The Director of Nursing and Staff Scheduler will be in-serviced on the regulation for required staffing levels.

The Nursing Home Administrator will monitor The Director of Nursing/designee to make certain state mandate is met daily for a period of two months.

Top Choice agency will be utilized as needed to bring additional staff as needed.

Human resources will continue to advertise for nursing staff to be employed.

Admissions will be on hold if staffing levels are not meeting the state mandates.

The results of the audits will be taken to QAPI meeting for review.

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(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 a review of nursing staffing hours and staff interview, it was determined that the facility did not ensure a minimum of one Licensed Nurse (LPN) for every 40 residents during the night shift on 13 of 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following staff scheduled for the resident census:

Night shift (requires one LPN per 40 residents)
On the following dates, one LPN was scheduled with a census of 41 residents:
July 2 and 8, 2023, September 4-9, 2023, and December 1-5, 2023.
This census level required two LPNs.

Interview with Nursing Home Administrator on December 6, 2023, at 1:30 p.m. confirmed that the above staffing levels did not meet the required minimums.



 Plan of Correction - To be completed: 02/05/2024

The nursing staff scheduler will schedule to meet the state mandates. Daily staffing levels will be audited daily by Director of Nursing/designee for a period of two months, to ensure that staffing levels provided are at or above the state and federal requirements that went into effect July 1, 2023.

The Director of Nursing and Staff Scheduler will be in-serviced on the regulation for required staffing levels.

The Nursing Home Administrator will monitor The Director of Nursing/designee to make certain state mandate is met daily for a period of two months.

Top Choice agency will be utilized as needed to bring additional staff as needed.

Human resources will continue to advertise for nursing staff to be employed.

Admissions will be on hold if staffing levels are not meeting the state mandates.

The results of the audits will be taken to QAPI meeting for review.

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

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