Pennsylvania Department of Health
FELLOWSHIP MANOR
Patient Care Inspection Results

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FELLOWSHIP MANOR
Inspection Results For:

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

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FELLOWSHIP MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated survey in response to a complaint completed on September 18, 2023, it was determined that Fellowship Manor was not in compliance with the following requirements of the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, 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 2.87 hours of direct resident care for each resident.

Observations:

Based on review of nursing staff schedules and staff interview, it was determined that the facility failed to meet the minimum nursing staff to resident ratios for three of 15 days reviewed.

Findings include:

A review of nursing time schedules for September 3, 2023, through September 17, 2023, revealed that the facility failed to meet minimum nursing staff to resident ratio of one licensed practical nurse (LPN) per 25 residents on day shift for September 3, and September 10, and one LPN per 40 residents on night shift for September 6, 2023.

In an interview on September 18, 2023, at 11:01 a.m., the Director of Nursing confirmed that the facility did not meet the minimum nursing staff to resident ratios on the identified dates.



 Plan of Correction - To be completed: 09/22/2023

No immediate corrective action was needed due to resident care not being compromised.
Nursing Administration will continue to review all staffing on a daily basis to ensure that have adequate staff to meet the resident needs.
To ensure that this does not occur, every effort will be made to meet the staffing ratios following our staffing practices. Those practices include communicating needs to internal and agency staff via electronic messaging platform, phone calls, emails etc. We also ask staff to come in early, stay later or switch shifts.
Nursing Administration will monitor the staffing ratios and nursing schedule on a daily basis. If at any time there is a risk that care would be compromised, Administration will assist with coverage on that shift.

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