Nursing Investigation Results -

Pennsylvania Department of Health
HAMPTON HOUSE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HAMPTON HOUSE
Inspection Results For:

There are  78 surveys for this facility. Please select a date to view the survey results.

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HAMPTON HOUSE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance Survey completed on January 15, 2020, it was determined that Hampton House 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 Requirements.






 Plan of Correction:


483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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.
483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of 483.95(g).
Observations:

Based on review of employee personnel files, select facility policy and facility in-service education records and staff interview, it was determined that the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide individualized in-service education accordingly.

The findings include:

A review of select employee personnel files and training records of nurse aides revealed no documented evidence that the facility had completed a performance review of these nurse aides the last 12 months.

A review of facility policy titled, "Abuse, Neglect and Misappropriation of Patient Property Prevention Policy Statement", dated November 13, 2019, indicated the Human Resource Director will ensure employee performance evaluations are completed by the employee's supervisor annually based on hire date.

During an interview January 15, 2020 at approximately 1:00 p.m. the Nursing Home Administrator confirmed that none of the nurse aides employed at the facility received a performance review in the past 12 months

The facility was unable to provide documented evidence that the above nurse aide employees had received specific in-service training based on the results of an annual performance review in the last 12 months.

.

28 Pa. Code 211.12 (c) Nursing services
Previously cited 12/14/18

28 Pa. Code 201.20 (a)(c)(d) Staff Development






 Plan of Correction - To be completed: 02/25/2020

Utilizing the employee file QAPI tool, select specific employee personnel files and training records of nurse aides was not identified in the CMS-2567L.
2. Current employees and new hires have the potential to be affected by the diffident practice. Utilizing the Employee File QAPI tool, the HRD will complete an audit to ensure nurse aides have received a performance review and completed individualized inserviced education accordingly.
3. To ensure the deficient practice does not recur, the facility Administrator will educate the nursing management and the expectation of completion of performance evaluations and individualized inservice education accordingly on or before the date of compliance.
4. Utilizing the employee file QAPI tool, the HRD will audit 5 employees per week times 4 weeks to ensure performance appraisals and individualized inservice education has been completed. The facility designee will report to the QAPI committee for further action planning if needed.
5. Facility states that the corrective action will be completed by February 25, 2020.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program: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.
483.80(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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:

Based on a review of the facility's antibiotic stewardship program and staff interview, it was determined the facility failed to fully develop and implement an antibiotic stewardship program.

Findings include:

A review of the facility's antibiotic stewardship program revealed the absence of written antibiotic use protocols on antibiotic prescribing, including the documentation of the indication, dosage, and duration of use of antibiotics.

There was also no indication of an established and operational system for the provision of feedback reports on antibiotic use, antibiotic resistance patterns based on laboratory data, and prescribing practices for the prescribing practitioner.

Interview with the Nursing Home Administrator on January 15, 2020, at approximately 10:40 a.m. confirmed that the facility had not established written antibiotic use protocols on antibiotic prescribing, including the documentation of the indication, dosage, and duration of use of antibiotics, and not implemented a system for the provision of feedback reports on antibiotic use, antibiotic resistance patterns based on laboratory data, and prescribing practices for the prescribing practitioner.




28 Pa. Code 211.12 (c) Nursing services
Previously cited 12/14/18

28 Pa. Code 211.10(a)(d) Resident care policies







 Plan of Correction - To be completed: 02/25/2020

No residents were negatively affected by the deficient practice.
2. Current residents and new admissions have the potential to be affected by the lack of antibiotic monitoring and prescribing practices.
3. To ensure the deficient practice does not recur, the facility DON and Infection preventionist will be educated on the Focus on Ftag 881 and the Antibiotic Stewardship module of the infection prevention manual on or before the date of compliance.
4. Utilizing the Antibiotic Stewardship Meeting Minutes, the DON will monitor the program monthly x 4 to ensure that Antibiotics are monitored per the facility specific prescribing practices. Any trends will be reported to the QAPI committee for further action planning.
5. Facility states that the corrective action will be completed by February 25, 2020.

483.10(j)(1)-(4) REQUIREMENT Grievances:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.10(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on observations, review of select facility policy and staff interviews, it was determined that the facility failed to fully develop a grievance policy, which included components necessary to ensure timely grievance resolution.

Findings included:


A review of the facility's policy entitled "Reporting a Concern/Grievance", (no revision date noted) revealed that the policy failed to identify how the facility will make information regarding how to file a grievance available to the residents, a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system.

The policy revealed failed to include procedures to maintain evidence demonstrating the results of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

Observations conducted throughout all facility nursing units on January 14, 2020, revealed a posting regarding the facility's grievance policy, which failed to include procedures designed to provide residents a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system.

During an interview on January 15, 2020, at 10:00 a.m. with the Nursing Home Administrator acknowledged that the facility failed to post and/or provide residents details of the grievance process to include procedures designed to support the resident's right to obtain a written decision regarding his or her grievance and related procedural information for contacting independent entities with whom grievances may be filed.


28 Pa Code 201.29 (i) Resident rights
Previously cited 12/14/18, 2/19/2019, 9/26/2019

28 Pa. Code 201.18(e)(1) Management
Previously cited 12/14/18, 2/19/2019, 9/26/2019







 Plan of Correction - To be completed: 02/25/2020

The facility's policy entitled Reporting Concern Grievance has been updated to reflect how the facility will make information regarding how to file a grievance available to the residents, a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed. In addition the policy will be updated to include procedures to maintain evidence demonstrating the results of all grievances for a period of no less than 3 years of the issuance of the grievance decision.
2. --
3. To ensure the deficient practice does not occur, the facility administration will post the appropriate Grievance policy to include the components above.
4. Utilizing the Administrative QAPI tool, the Administrator will audit weekly times 4 weeks to ensure required grievance posting is in place. Any trends will be reported to the QAPI committee for further action planning if needed.
5. Facility states that the corrective action will be completed by February 25, 2020.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on observation, review of manufacturer's operation manual and directions for use and staff interview, it was determined that the facility failed to maintain an environment free from potential accident hazards on the A and B Wing Central bathing areas.

Findings include:

Review of the manufacturer's operation manual and directions for use for the Arjo Maxi Move lift (page 33, 2006) revealed that the charger for the lift batteries should only be used in a dry environment and not charged in a bathroom.

Observations of the A-wing and B-wing central bathing areas during the initial environmental tour on Janaury 12, 2020, at approximately 9:50 a.m. and 1:14 p.m. and again on Janaury 13, 2020, at approximately 8:45 a.m. and 12:35 p.m., revealed that the batteries for the above noted lifts were charging in the electrical outlet located on the wall.

Interview with the nursing home administrator on January, 2020, at approximately 9:50 a.m. confirmed that the batteries for the mechanical lifts were charged in the central bathing area, potentially exposing them to moisture.



483.25(d)(1) Free of Accidents Hazards
Previously cited 12/14/18

28 Pa. Code 211.12 (c)(d)(5) Nursing services.
Previously cited 2/19/19, 12/14/18









 Plan of Correction - To be completed: 02/25/2020

On January 12, 2020, the Arjo lift batteries were removed form the central bathing areas and relocated to a dry environment by Maintenance.
2. The facility designee will ensure that, per the manufacturer's operating manual, the charger for the lift batteries will only be used in a dry environment.
3. To ensure the deficient practice does not recur, the DON and/or designee will educate nursing staff on location of Arjo lift batteries and charging stations.
4. Utilizing the Arjo lift QAPI tool, the maintenance director will monitor weekly times 4 weeks, to ensure that the ARGO lift batteries are stored in a dry location. Any trends will be reported to the QAPI committee for further action planning if needed.
5. Facility states that the corrective action will be completed by February 25, 2020.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:

Based on review of clinical records and select facility guidelines and staff interview, it was determined that the facility failed to provide nursing services consistent with professional standards of quality according to Title 49, Professional and Vocational Standards during the tuberculin skin testing for one of 19 residents reviewed (Resident 51)

Findings include:

A review of Resident 51's clinical record revealed that he received step one, of the two step PPD skin test (PPD -Purified Protein Derivative - a solution used to test for Tuberculosis, a potentially serious infectious bacterial disease that mainly affects the lungs) on March 10, 2019. The test was administered by Employee 1 (LPN- Licensed Practical Nurse). Employee 1 also administered a PPD on May 21, 2019


According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: 21.145(e) "The LPN may administer immunizing agents and do skin testing only if the following conditions are met: (3) Written policies and procedures under which the LPN may administer immunizing agents do skin testing have been established by a committee representing the nurses, the physicians and the administration of the agency or institution employing or having jurisdiction over the LPN. A current copy of the policies and procedures shall be provided to the LPN at least once every 12 months. The policies and procedures shall provide for: (i) Identification of the immunizing and skin testing agents which the LPN may administer; (ii) Determination of contradictions for the administration of specific immunizing and skin testing agents; (iii) The listing, identification, description, and explanation of principles, including technical and clinical indications, necessary for the identification and treatment of possible adverse reactions; (iv) Instruction and supervised practice required to insure competency in administering immunizing and skin testing agents."

A review of the facility's current guidelines entitled "Tuberculosis Screening" indicated that a two step Mantoux ( tuberculosis screening by a injection under the skin) test is administered, per physicians orders, to patients within 24 hours of admission in order to establish a reliable baseline and read within 48-72 hours of administration and step 2 is administered 1-3 weeks after reading the first step.

The guideline failed to identify if a licensed practical nurse or registered nurse was to administer and read the tuberculin skin tests.

Further review of the facility's TB policy, failed to reflect the requirements of the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) that the policies and procedures shall provide for: (i) Identification of the immunizing and skin testing agents which the LPN may administer; (ii) Determination of contradictions for the administration of specific immunizing and skin testing agents; (iii) The listing, identification, description, and explanation of principles, including technical and clinical indications, necessary for the identification and treatment of possible adverse reactions.


An interview with the Director of Nursing (DON) on January 15, 2020, at 11:30 AM verified that LPNs administer PPD skin testing to residents.

Facility LPNs administered and read TB skin tests for resident,s but the facility failed to provide documentation to demonstrate that staff LPNs were provided with the current policies and procedures related to skin testing, which included the above professional requirements (contradictions and adverse reactions).

The facility was unable to provide evidence that the LPN's received and satisfactorily completed a Board approved educational programs which requires study and supervised practice intended to provide training necessary for administering immunizing agency and performing skin testing as required by the State Board of Nursing.


The facility's nursing staff failed to demonstrate the provision of care as set forth under Title 49, Professional and Vocational Standards, Department of State, Chapter 21.11(a)(4) Responsibilities of the Registered Nurse indicated the Registered Nurse implements and evaluated nursing care for individuals for whom responsible and carries out nursing care actions which promote, maintain and restore the well-being of individuals and (b), The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered.

According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: 21.145(a) the LPN is prepared to function as a member of the health care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place.




28 Pa. Code 201.19 Personnel policies and procedures

28 Pa. Code 201.20(a) Staff development

28 Pa. Code 201.22(a) Prevention, control, and surveillance of tuberculosis (TB)

28 Pa. Code 211.10 (a)(d) Resident care policies

28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services
Previously cited 12/14/18, 2/19/19, 12/3/19




















 Plan of Correction - To be completed: 02/25/2020

Resident 51 did not have a negative outcome related to an LPN administering a tuberculin skin test.
2. Current residents and new admissions who receive the tuberculin skin testing have the potential to be affected by the deficient practice. Utilizing the TB Administration QAPI tool, residents will be evaluated for completion of tuberculin testing to ensure a negative outcome does not occur in relation to an LPN administering a tuberculin.
3. To ensure the deficient practice does not reoccur, the facility DON and/or designee will educate the nursing staff on "Focus on F tag 658" and the PA code Title 49, Professional and Vocational standards department of state, Chapter 21 State board of nursing, Chapter 21.145 Functions of the LPN. Effective January 23, 2020, RNs will administer PPDs moving forward.
4. Utilizing the TB Administration QAPI tool, the DON and/or designee will monitor 5 residents per week times 4 weeks to ensure that RN has provided administration of the TB. Any trends will be reported to the QAPI committee for further action planning if needed.
5. Facility states that the corrective action will be completed by February 25, 2020.

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 clinical record review, and staff interview, it was determined that the facility failed to timely notify the physician of significant weight changes for two of five sampled residents (Resident 44 and 88).

Findings include:

A review of the clinical record revealed that Resident 44 was admitted to the facility on June 23, 2011, and had diagnoses that included hypertension and anorexia (an eating disorder characterized by abnormally low body weight).

A review of the resident's weight record revealed the following:

January 3, 2019 219.0 lbs
February 3, 2019 216.8 lbs
March 1, 2019 213.8 lbs
April 2, 2019 206.4 lbs
May 1, 2019 201.6 lbs
June 2, 2019 198.6 lbs
July 4, 2019 187.8 lbs - a 10.8 lb or 5.4% significant weight loss in one month
July 8, 2019 188.4 lbs

The was no documented evidence that the physician was notified of the resident's significant weight loss noted on July 4, 2019.

Clinical record review revealed that Resident 88 was admitted to the facility on September 15, 2019, and had diagnoses that included diabetes, and other symptoms and signs concerning food and fluid intake.

A review of the resident's weight record revealed the following:

September 15, 2019 198.0 Lbs
September 17, 2019 198.0 Lbs
September 24, 2019 198.0 Lbs
October 1, 2019 200.0 Lbs
October 8, 2019 200.0 Lbs
October 15, 2019 200.0 Lbs
November 2, 2019 242.6 Lbs 42.6 pound or 21.3% significant weight gain
November 4, 2019 245.4 Lbs


There was no evidence that the physician was notified of the significant weight gain noted on November 2, 2019. The physician did not note awareness of the weight gain until December 5, 2019, according to a general progress note.

Interview with the Administrator on January 14, 2020, at 9:45 a.m., confirmed that the physician was not notified timely of the above significant weight changes.




28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing services
Previously cited 12/14/18, 2/19/19, 12/3/19












 Plan of Correction - To be completed: 02/25/2020

1. Resident 44 and 88 physicians have been notified by the licensed nurse of the patient's current weight status.
2. Current residents who have a significant weight loss/gain have the potential to be affected by the deficient practice. Residents with significant weight loss/gain will be evaluated using the Weight QAPI tool to ensure notifications to the physician are completed and documentation is present by the licensed nurse.
3. To ensure the deficient practice does not occur, the facility DON and/or designee will educate the nursing staff on "Focus on F tag 580" and center's process of change of condition on or before the date of compliance.
4. Utilizing the Weight QAPI tool, the DON and/or designee will audit 5 residents with significant weight loss/gain weekly times 4 weeks to ensure physician notification has been completed. Any trends will be reported to the QAPI committee for further action planning if needed.
5. Facility states that the corrective action will be completed by February 25, 2019.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations: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.
483.80(d) Influenza and pneumococcal immunizations
483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to offer and/or provide the influenza and pneumococcal immunization to two of seven residents reviewed (Residents 390 and 391).

Findings include:

Review of the clinical record of Resident 390 revealed admission to the facility on December 30, 2019. At the time of review during the survey ending January 15, 2020, there was no documentation verifying that the facility had offered and/or provided the influenza and pneumococcal immunization to Resident 390.

Review of the clinical record of Resident 391 revealed admission to the facility on December 27, 2019. At the time of review during the survey ending January 15, 2020, there was no documentation verifying that the facility had offered and/or provided the influenza and pneumococcal immunization to Resident 391.

Interview with the Director of Nursing on January 14, 2020, at approximately 9:30 a.m. confirmed that there was no evidence that Residents 390 and 391 were offered and/or provided the influenza and pneumococcal immunizations.



28 Pa Code 211.12 (a)(c)(d)(1)(5) Nursing services
Previously cited 12/14/18, 2/19/19, 12/3/19

28 Pa Code 211.5 (f) Clinical records.
Previously cited 12/14/18









 Plan of Correction - To be completed: 02/25/2020

Resident 391 has been discharged from the facility. Resident 390 will be screened for the influenza and pneumococcal immunization and clinically indicated the patient representative will be notified to obtain consent and if consent given, the attending physician will be notified for additional orders, and immunizations administered as ordered by the licensed nurse.
2. Current residents who did not receive the flu and pneumococcal vaccine will be offered the flu and pneumococcal vaccine. Utilizing the 2019 Immunization QAPI tool, current residents and new admissions will be reviewed to ensure that flu and pneumococcal vaccinations are given as clinically indicated on or before the date of compliance.
3. To ensure the deficient practice does not occur, the facility DON and/or designee will educate the nursing staff on "Focus on F tag 883" and the infection control manual chapter 9 Screenings and Immunizations on or before the date of compliance.
4. Utilizing the Admission Eagle Room tool, the DON and/or designee will audit 5 new admissions per week times 4 weeks to ensure that flu and pneumococcal are offered. Any trends will be reported to the QAPI committee for further action planning if needed.
5. Facility states that the corrective action will be completed by February 25, 2020.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on clinical record review and staff interviews it was determined that the facility failed to demonstrate the clinical necessity of the administration of psychoactive drugs by failing to consistently monitor resident's identified and targeted behavioral symptoms being treated with psychoactive medications and the use and effectiveness of non-pharmacological behavioral interventions attempted for two residents out five sampled (Residents 23 and 19).


Findings included:


Interview with the Director of Nursing and Nursing Home Administrator on January 14, 2020, at approximately 2:15 p.m., revealed all resident behaviors are documented in progress notes. The DON and NHA stated that the facility does not use any other means for behavioral symptom tracking. The facility does not maintain documentation of the implementation or effectiveness of care plan interventions designed to address residents' behavioral symptoms

A review of the clinical record revealed Resident 23 was admitted to the facility on November 14, 2018, and had diagnoses, which included unspecified dementia (Irreversible, progressive degenerative disease of the brain, resulting in loss of reality and functioning ability) without behavioral disturbance and major depressive disorder.

Review of Resident 23's Annual Minimum Data Set (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 2, 2019, revealed the resident was unable to be interviewed for a BIMS due to severe cognitive impairment. Review of Section E Behavior revealed resident had verbal behavioral symptoms 1-3 days during review period.

The resident's current care plan last revised October 11, 2019, identified behavioral symptoms of distressed mood/behavior as evidenced by verbal, physical agitation, aggression, unprovoked outbursts, argumentative, and agitated towards others due to Dementia. Interventions included offering snacks such as chocolate, involve in 1:1 recreational activities, providing resident "jobs" such as folding items, and providing books or magazines.

Review of Resident 23's clinical record revealed that the resident was prescribed Trazodone (antidepressant) 25 mg at bedtime for Depression, Depakote 125 mg (medication known as an anticonvulsant that is used to treat the manic symptoms of bipolar disorder) at 6:00 p.m daily, and 250 mg daily in the a.m for Dementia, Klonopin .5 mg (his medication is known as an anticonvulsant or antiepileptic drug. It is also used to treat panic attacks. Clonazepam works by calming your brain and nerves. It belongs to a class of drugs called benzodiazepines) BID for anxiety and Zyprexa 2.5 mg (antipsychotic drug) at bedtime for hallucinations/delusions.

Further review of the resident's clinical record revealed that there was no documentation that the facility monitored effectiveness of these psychoactive drugs in the management of resident's behavioral symptoms and improving the resident's functional status.

Further review of Resident 23's clinical record on January 14, 2020, revealed no documented behaviors since a nurses note dated November 22, 2019 indicating that the resident was having "periodic outbursts."

A review of the clinical record revealed Resident 19 was admitted to the facility on May 26, 2016, with diagnoses, which included unspecified dementia (Irreversible, progressive degenerative disease of the brain, resulting in loss of reality and functioning ability) without behavioral disturbance and unspecified psychosis.

Review of Resident 19's Quarterly Minimum Data Set (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 31, 2019, revealed the resident was unable to be interviewed for a BIMS due to severe cognitive impairment. Review of Section E Behavior revealed resident had no behaviors during review period.

The resident's current care plan last revised November 11, 2019, identified distressed mood/behavior as evidenced by resistive/noncompliant, attempting to self transfer and stand up without assistance, removing nonskid socks and shirt, rolling backwards in wheelchair, verbal, physical agitation aggression due to dementia. Interventions included allowing flexibility in routine, providing education to resident, and providing non-care related conversation.

Review of Resident 19's clinical record revealed that the resident was prescribed Risperidone .75 mg (antipsychotic drug) at bedtime, and .25 mg in a.m., for dementia with psychosis.

Further review of the resident's clinical record revealed that there was no documentation that the facility monitored effectiveness of the antipsychotic drug in the management of resident's behavioral symptoms and improving the resident's functional status.

Further review of Resident 19's clinical record on January 14, 2020, revealed no documented behaviors, since a nurses note dated November 24, 2019 indicating that resident was inappropriately disrobing.

Interview with the Director of Nursing and Nursing Home Administrator on January 14, 2020 at approximately 2:15 p.m., confirmed that all resident behaviors are to be documented in progress notes and that the facility does not any other means for behavioral tracking.

No documentation was available at the time of the survey ending January 15, 2020, that the facility had tracked the consistent use and effectiveness of the care planned non-pharmacological interventions designed to address these resident's dementia related behavioral symptoms.

Interview with the Nursing Home Administrator on January 15, 2020, at approximately 8:45 AM, was unable to provide documented evidence the implementation of individualized person-centered non-pharmacological interventions to address Resident 23's and 19's dementia-related behaviors.




28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services
Previously cited 12/14/18, 2/19/19, 12/3/19

28 Pa Code 211.11 (d) Resident Care Plan
Previously cited 12/14/18, 2/19/19, 9/26/19








 Plan of Correction - To be completed: 02/25/2020

Residents 23 and 19 current psychoactive medications and current behaviors have been reviewed by the attending MD and adjustments made as clinically indicated.
2. Current residents who demonstrate the clinical necessity of the administration of psychoactive drugs will be monitored and documented on the use on non-pharmacological interventions. Utilizing the behavior QAPI tool, residents demonstrating behaviors will be evaluated to ensure appropriate treatment and care interventions are in place on or before the date of compliance.
3. To ensure the deficient practice does not occur, the facility DON and/or designee will educate the nursing staff on "Focus on F tag 758" and the behavior practice guide related to behaviors and non pharm interventions.
4. Utilizing the Behavior Eagle Room tool, the DON and/or designee will audit 5 residents per week times 4 weeks to ensure no pharmacological interventions are documented in the clinical record. Any trends will be reported to the QAPI committee for further action planning if needed.
5. Facility states that the corrective action will be completed by February 25, 2020.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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.
483.45(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

483.45(c)(2) This review must include a review of the resident's medical chart.

483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on a review of clinical records and medication prescribing information and staff interview, it was determined that pharmacist failed to identify drug irregularities in the medication regimen of two residents out of 19 sampled (Residents 43 and 44).

Findings include:

A review of the Federal Drug Administration (FDA) prescribing information indicated that Colesevelam (brand name, Welchol - a medication used to treat high cholesterol) can make certain medications including thyroid medication, less effective and should be given four hours before Welchol because it can interfere with the absorption of other medications.

A review of the clinical record revealed that Resident 43 was re-admitted to the facility on November 12, 2019, and had diagnoses that included diabetes (elevated blood sugar levels) hypercholesterolemia (elevated levels of cholesterol) and disorder of the thyroid (which can cause dry skin, constipation, depression, fatigue and nervousness)

The resident had a physician's order dated November 20, 2019, remaining current at the time of the survey ending January 15, 2020, for Colesevelam 625 milligrams (mg), three tablets twice a day at 8:00 a.m. and at 12:00 p.m. with breakfast and lunch and for Levothyroxine (a medication for an overactive thyroid gland) 75 mg once a day at 6:00 a.m. and increased to 100 mg on December 10, 2020, once a day at 6:00 a.m..

A review of the November and December 2019 Medication Administration Records (MAR) and Janaury 2020 MAR, revealed that Resident 43 received his Levothyroxine medication two hours before his Colesevelam medication, every day since his re-admission of Novemeber 12, 2019, to the facility.

A review of the monthly "Medication Regimen Reviews" conducted by the pharmacist on November 19, 2019 and on December 16, 2019 revealed no indication that the pharmacist identified the drug irregularity, involving the administration time of these two medications within two hours of each other.

During an interview with the Nursing Home Administrator (NHA) on January 15, 2020, at approximately 11:25 a.m. the NHA was unable to explain why there was no evidence that the pharmacist had identified the potential drug irregularity and why the medication was not given in accordance with pharmacy guidelines.

Clinical record review revealed that Resident 44 was admitted to the facility on June 23, 2011, and had diagnoses that included depression, anxiety and schizophrenia (A mental disorder characterized by delusions, hallucinations, disorganized speech and behavior).

The resident had a physician's order that was in effect for the last year (facility could not supply an initial medication start date) remaining current at the time of the survey ending January 15, 2020, for Citalopram (used to treat depression) 20 mg given once daily at 8:00 p.m. for depression.

A review of the monthly "Medication Regimen Reviews" conducted by the pharmacist from January 2019 through December 2019, revealed no indication that the pharmacist identified the absence of an attempt at a gradual dose reduction of the Citalopram 20 mg.

Interview with the Administrator on January 15, 2020, at approximately 9:25 a.m. confirmed that there was no evidence that the pharmacist had identified the lack of a gradual dose reduction attempt in the last year and the continued use and dose of the Citalopram medication.



28 Pa. Code 211.9 (k) Pharmacy services.

28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.
Previously cited 2/19/19, 12/14/18































 Plan of Correction - To be completed: 02/25/2020

Resident 43 administration times of Welchol and Synthroid have been reviewed and changed accordingly by the licensed nurse. Resident 44 use of Citalopram has been reviewed by the attending physician and adjusted as clinically indicated.
2. Current residents who are on Welchol and Synthroid and current residents receiving antidepressants have the potential to be affected by the deficient practice. Utilizing the Psychoactive Medications QAPI tool, residents receiving antidepressants will be reviewed by the attend MD for possible GDR. No other residents currently receive Welchol and Synthroid.
3. To ensure the deficient practice does not occur, the facility DON and/or designee will educate the nursing staff on "Focus on F tag 756" and the FDA Prescribing information for Welchol and thyroid medication, and the facility behavior practice guide related to indications for GDRs on or before the date of compliance.
4. Utilizing the Psychoactive Medications QAPI tool, the DON and/or designee will monitor 5 residents weekly times 4 to ensure correct prescribing of Welchol and/or antidepressant medication. Any trends will be reported to the QAPI committee for further action planning if needed.
5. Facility states that the corrective action will be completed by February 25, 2020.

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 a review of clinical records and staff interview, it was determined that the facility failed to address a resident's current clinical status and treatment on the resident's comprehensive plan of care for one resident out of two residents sampled (Resident 57).

Findings include:

According to review of the clinical record, on November 17, 2019 at 4:46 p.m. Resident 57 vomited once yellow in color. The Medical Doctor (MD) was notified and an order for chest x-ray, and lab work was obtained. At 5:51 p.m. the chest x-ray was taken and at 9:54 p.m. the x-ray results were obtained, and the MD was notified with no new orders.

On November 18, 2019 at 12:12 p.m. the nursing documentation revealed the lab results were obtained and the MD was notified of their results. New orders were received to transfer Resident 57 to the emergency room (hospital) for evaluation.

On November 28, 2019 at 6:56 a.m. nursing documentation noted "Treatment intact to sacrum, cont (continues) on two ABT (antibiotic therapy) for osteomyelitis for same"

A review of November 2019 Medication Administration Record (MAR) revealed the antibiotic being administered.

A review of the current MAR (January 2020) revealed that the resident continued to receive antibiotics for treatment of osteomyelitis (an infection of the bone).

A review of Resident 57's current comprehensive plan of care conducted on January 14, 2020, revealed that the resident's care plan did not address the resident's osteomyelitis and ongoing treatment with antibiotic therapy.

Interview with the Nursing Home Administrator on January 15, 2020, at approximately 8:30 a.m., confirmed the absence Resident 57's Osteomyelitis on the resident's care plan.






28 Pa Code 211.11(d) Resident care plan.

28 Pa Code 211.12 (c)(d)(3)(5)Nursing Services.




 Plan of Correction - To be completed: 02/25/2020

Resident 57 has had a care plan implemented for Osteomyelitis and antibiotic therapy.
2. Current residents who are on an antibiotic, have the potential to be affected by the deficient practice. Utilizing the infection QAPI tool, residents on an antibiotic will be evaluated to ensure all residents on an antibiotic have a Care Plan to reflect such.
3. To ensure the deficient practice does not recur, the facility DON and/or designee will educate the nursing staff on "Focus on F tag 656" and Interdisciplinary Care Planning on or before the date of compliance.
4. Utilizing the Infection QAPI tool, the DON and/or designee will audit 5 residents per week times 4 weeks to ensure that residents on an antibiotic will be evaluated to ensure all residents on an antibiotic have a Care Plan to reflect such.
5. Facility states that the corrective action will be completed by February 25, 2020.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:

Based on review of the Notice requirements before Transfer/ Discharge sent to residents and resident representatives and staff interview, it was determined the facility failed to notify residents and their representatives of the residents' transfers or discharge and the reasons for the move in writing in a language and manner, which they understand for three residents out of 18 residents reviewed (Residents 51, 80 and 35 )

Findings include:

A review of the clinical record revealed that Resident 51 was transferred to the hospital on September 29, 2019 and returned October 7, 2019. The transfer documentation did not indicate the reason for resident's transfer and the destination, failed to include the name of the State Long Term Care Ombudsman and information on how to complete an appeal form. This same resident was transferred to the hospital on November 5, 2019, and returned on November 14, 2019. The transfer letter did not include the reason for transfer in a language and manner that the resident could easily understand. The reason for transfer was noted as 'low oxygen concentration." The notice also lacked the State Long Term Care Ombudsman's name and how to complete an appeal form.

Resident 80 was transferred to the hospital on September 2, 2019 and returned on September 8, 2019. The notice provided failed to name the State Long Term Care Ombudsman and also failed to include information on how to complete an appeal form.

Resident 35 was transferred to the hospital on December 28, 2019 and returned on December 29, 2019. A review of the written notice provided revealed that this notice did not include the reason for transfer, written in a manner and language the resident and/or the residents' representatives could understand, stating solely that "The reason for this discharge/transfer is necessary for the welfare and needs of the resident cannot be met by the facility." The notice also failed to include information regarding the resident's appeal rights, including the name address, (mailing and e-mail), and telephone number of the entity which receives such requests and information on how to obtain and complete an appeal form. The notice did not identify the location to which the resident was transferred and the date of transfer.

During an interview with the Nursing Home Administrator (NHA) on January 14, 2019, at 1:00 p.m. it was revealed that the facility changed their transfer forms after October 2019, and confirmed that the required information was not included on the above noted forms.


28 Pa. Code 201.14 (a) Responsibility of licensee

28 Pa. Code 201.29 (h) Resident rights








 Plan of Correction - To be completed: 02/25/2020

Resident 51 patient representative has been provided the reason for transfer to the hospital on September 29, 2019 and November 5, 2019 by licensed nurse. Resident 80 has been provided the reason for transfer to the hospital on September 2, 2019 by licensed nurse. Resident 35 no longer resides in the facility.
2. Current residents residing in the facility who have had a transfer out to the hospital from 1/1/2020 to date of compliance have the potential to be affected by the deficient practice. Using the Unplanned Rehospitalization QAPI tool, residents who have been transferred to the hospital from 1/1/2020 to current will be reviewed to ensure the proper notification has been given, to include in writing in a language and manner which they understand on or before the date of compliance.
3. To ensure the deficient practice does not occur, the facility DON and/or designee will educate the nursing staff on "Focus on F tag 623", Acute Transfer Form, and the Facility Initiated Transfer discharge notice, on or before the date of compliance.
4. Utilizing the Unexpected Hospital Readmission QAPI tool, the DON and/or designee will audit 5 residents per week times 4 weeks to ensure the proper notification has been given, to include in writing in a language and manner which they understand on or before the date of compliance. Any trends will be reported to the QAPI committee for further action planning if needed.
5. Facility states that the corrective action will be completed by February 25, 2020.

483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
483.12(b) The facility must develop and implement written policies and procedures that:

483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

483.12(b)(3) Include training as required at paragraph 483.95,
Observations:

Based on a review of employee personnel files, training records and the facility's abuse prohibition policy and procedures and staff interviews revealed that facility failed to implement its abuse prohibition policy and procedures by failing to promptly train one employee out of five reviewed (Employee 2 ) on the facility's specific abuse prohibition procedures.

Findings include:

A review of the faciity's abuse policy dated as reviewed by the facility November 2019 indicated that the Abuse Prevention Coordinator holds training for faciity staff upon hire or placement and at least annually thereafter.

Review of the personnel files of employees hired since the last standard survey ending December 14, 2018, revealed that Employee 2 (housekeeping aide employed by a contracted service) began working in the facility November 4, 2019, but was not educated on the facility's abuse prohibition policy and procedures.

The Director of Housekeeping stated during interview on January 15, 2020, that Employee 2 was inserviced on their company's abuse policy, but not the faciity's specific abuse policy and procedures. A review of the policy from the contracted housekeeping service revealed that it differed from the facility's policy and did not include all regulatory required components.


28 Pa. Code 201.20(b) Staff Development

28 Pa. Code 201.19 Personnel policies and procedures









 Plan of Correction - To be completed: 02/25/2020

Employee 2 is no longer employed by HSG.
2. Utilizing the employee file QAPI tool, an audit will be completed to ensure that employees, including contracted services, have been education upon hire and annually have been educated on the prohibition of the facilities abuse policy and procedure on or before the date of compliance.
3. To ensure the deficient practice does not occur, the facility designee will educate the department managers, including the contracted managers, to education the staff upon hire and annually. Random audits will be completed on 3 employees per week to validate that appropriate training has been provided per the abuse prevention policy.
4. Utilizing the Employee File QAPI tool, the department manager will audit 5 new hires weekly times 4 to ensure education on the facilities education on the facilities prohibition on the Abuse policy has been completed. Any trends will be reported to the QAPI committee for further action planning if needed.
5. Facility states that the corrective action will be completed by February 25, 2020.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observations and staff interview, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean and sanitary environment and resident care equipment for one of 19 residents (Resident 4).

Findings include:

Observations of Resident 4's tube feeding equipment on Janaury 12, 2020, at 10:01 a.m. and 1:55 p.m., on January 13, 2020 at 8:17 a.m. and at 1:25 p.m. and on Janaury 14, 2020 at 9:17 a.m., revealed that the resident's tube feeding stand and frame were soiled with dried tube feeding solution. In addition, the top on the resident's dresser near the pump and the head board on the resident's bed were also soiled with spilled tube feeding solution.

Interview with the nursing home administrator administrator on Janaury 15, 2020, at approximately 9:05 a.m., confirmed that resident equipment and the environment were to be maintained in a clean and sanitary manner.



483.10(i)(2) Safe, clean, comfortable and homelike environment
Previously cited 12/14/18

28 Pa. Code 207.2(a) Administrator's Responsibility.
Previously cited 12/14/18













 Plan of Correction - To be completed: 02/25/2020

1. Resident 4 tube feeding stand and frame, top of dresser near the pump and headboard have been cleaned by Housekeeping.
2. Current residents that have a tube feeding have the potential to be affected by the deficient practice. Residents that have a tube feed will have their environment evaluated using the Environmental Observations QAPI tool by Housekeeping to ensure that the environment is free from any tube feed spillage.
3. To ensure the deficient practice does not occur, the housekeeping supervisor will educate the housekeeping staff on "Focus on F tag 584" and written policy from HSG on cleaning equipment on or before the date of compliance.
4. Utilizing the Environmental Observations QAPI tool, the housekeeping supervisor will audit 5 residents per week for 4 weeks to ensure cleanliness of tube feeding equipment and surroundings. Any trends will be reported to the QAPI committee for further action planning if needed.
5. Facility states that the corrective action will be completed by February 25, 2020.

211.9(g) LICENSURE Pharmacy services.:State only Deficiency.
(g) If over-the-counter drugs are maintained in the facility, they shall bear the original label and shall have the name of the resident on the label of the container. The charge nurse may record a resident's name on the nonprescription label. The use of nonprescription drugs shall be limited by quantity and category according to the needs of the resident. Facility policies shall indicate the procedure for handling and billing of nonprescription drugs.
Observations:

Based on observation and staff interview it was revealed that over the counter medications were not labeled with the names of two of two residents (Residents 87 and 13 ) observed receiving these medications during the medication administration pass.

Findings include:

A review of an exception granted by the State Licensing Agency on January 22, 2016, indicated that if over the counter medications are utilized by the facility a list of them will be kept in the front of each medication administration record on each medication cart, it will include a list of the over the counter medications with the names of the residents.

Observation of the medication administration to Resident 87 on January 13, 2020, at 8:20 a.m. revealed he resident had a physician's order and received house stock Tylenol 325 mg two tablets, FeS04 iron supplement) 325 mg one tablet, and OsCal + Vitamin D 500 mg one tablet.

Observation of the medication administration to Resident 13 on January 13, 2020, at 8:30 a.m. revealed the resident had a physician's order and received house stock Vitamin D 1000 units one tablet and Multivitamin with minerals one tablet.

Observation of the labels on the containers of the above over the counter medications revealed they did not bear the residents' names.

Interview with the Director of Nursing on January 13, 2020 at 11:30 a.m. confirmed the names of all residents in the facility receiving house stock over the counter medications were not on the label of the medication bottles at the time of the observations nor were stock medication lists available in each medication administration record as the facility indicated when requesting the exception to the state licensure regulation on January 22, 2016.










 Plan of Correction - To be completed: 02/25/2020

Resident 87 and 13 did not have a negative outcome related to not having a house stock over the counter medication list.
2. To ensure the deficient practice does not recur the facility will initiate a master log of house stock over the counter medications specific to each patient on or before the date of compliance.
3. To ensure the deficient practice does not occur, the facility DON and/or designee will educate the nursing staff on the facilities initiative master log of house stock over the counter medications.
4. The facility will monitor weekly times 4 to ensure that residents do not have a negative outcome related to not having a house stock over the counter medication list.
5. Facility states that the corrective action will be completed by February 25, 2020.


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