Nursing Investigation Results -

Pennsylvania Department of Health
GROVE AT GREENVILLE, THE
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GROVE AT GREENVILLE, THE
Inspection Results For:

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GROVE AT GREENVILLE, THE - 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 a complaint, completed on February 6, 2020, it was determined that The Grove at Greenville 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:


483.75(a)(2)(h)(i) REQUIREMENT QAPI Prgm/Plan, Disclosure/Good Faith Attmpt: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.
483.75(a) Quality assurance and performance improvement (QAPI) program.

483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation;

483.75(h) Disclosure of information.
A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section.

483.75(i) Sanctions.
Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.
Observations:

Based on review of facility policies and documentation and staff interview, it was determined that the facility failed to develop and utilize a Quality Assurance Performance Improvement (QAPI - a framework utilized to guide an organization's performance improvement efforts) Plan.

Findings include:

The facility policy entitled "Quality Assurance/Performance Improvement" dated 1/17/20, indicated that the facility will have an ongoing plan, consistent with available community and facility resources, to provide or make available services that meet the medically-related needs of it's residents and that the plan would be reviewed regularly to insure that policy, procedure and adherence to standards and regulations is attained and maintained.

Upon request, the facility was not able to provide the survey team with the facility's QAPI Plan for 2020.

During an interview on 2/06/20, at 10:07 a.m. the Director of Nursing (facility designee who oversees the QAPI committee) confirmed that the facility did not have a current facility QAPI plan to provide a framework to assure consistency in the collection of data, data tracking, goal setting, prioritizing, analyzing and monitoring for deficiencies or areas identified for by the QAPI committee.

28 PA Code 201.14(a) Responsibility of licensee
Previously cited 11/15/19

28 PA Code 201.18(b)(1) Management
Previously cited 11/15/19, 4/25/19

28 PA Code 201.18(e)(1) Management

28 PA Code 211.10(b) Resident care policies








 Plan of Correction - To be completed: 02/18/2020

F865
"The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements."



1. The facility had a Quality Assurance Performance Improvement (QAPI) plan that was implemented and rolled out in 2018 which was to provide framework to assure consistency in the collection of data, data tracking, goal setting, prioritizing, analyzing and monitoring for deficiencies or areas identified for by the QAPI committee.
2. The facilities Quality Assurance Performance Improvement policy was reviewed and will be re-implemented on 2/13/20. The plan is located in the front of our DOH entrance binder.
3. The QAPI Committee will be re-educated on the facility Quality Assurance Performance Improvement Plan by the Nursing Home Administrator/designee.
4. The Nursing Home Administrator/designee will audit monthly Quality Assurance Performance Improvement meetings to ensure the facility's QAPI plan is being followed. This will be an ongoing audit.



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