Pennsylvania Department of Health
HOLY FAMILY MANOR
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HOLY FAMILY MANOR
Inspection Results For:

There are  98 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.
HOLY FAMILY 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 February 6, 2024, it was determined that Holy Family Manor 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 as they relate to the Health portion of the survey process.



 Plan of Correction:


483.70(a)-(c) REQUIREMENT License/Comply w/ Fed/State/Locl Law/Prof Std: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.
§483.70(a) Licensure.
A facility must be licensed under applicable State and local law.

§483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards.
The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.

§483.70(c) Relationship to Other HHS Regulations.
In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.
Observations:

Based on review of the LPN (Licensed Practical Nurse) Act, clinical record review and staff interviw, it was determined that the facility failed to ensure that professional standards of quality regarding the administration of physician prescribed medications was followed for one of four residents that received medication. (Resident 1)

Findings include:

Pa. Code Title 49 Professional and Vocational Standards Department of State Chapter 21, State Board of Nursing 21.145 Function of the Licensed Practical Nurse states that the LPN is prepared to functions as a member of the health care team based on preparation, knowledge, skills and understanding of past experiences in nursing situations and the LPN administers medications and carries out the therapeutic treatments ordered for the patient.

Clinical record review revealed that Resident 1 had diagnoses that included COPD (chronic obstructive pulmonary disease), anxiety and hypotension. Clinical record review revealed that on January 31, 2024, at 9:40 p.m. LPN 1 failed to identify Resident 1 by name band identification, photo identification or verbal confirmation prior to the administration of medications. As a result, Resident 1 received another resident's medications in error including a medication to treat hypertension (Lisinopril),a medication for schizophrenia (Quetiapine), a medication for tremors (Ropinirole) and a medication for depression (Mirtazapine).

In an interview on February 6, 2024, at 11:10 a.m., the Director of Nursing confirmed that LPN 1 failed to follow the accepted standard of identifying a resident prior to the administration of medication.

28 Pa. Code 211.12(d)(1)(5) Nursing services.









 Plan of Correction - To be completed: 02/17/2024

Department of Health Plan of correction for February 06, 2024, preparation and /or execution of this Provider's 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 as perceived by representatives of the Department of Health relative to the on-site survey concluded on February 06, 2023. The provider's Plan of Correction is prepared solely because it conveys this sincere message of the governing body, as follow: All representative entities of Holy Family Manor("HFM") have been, are, and will be committed to providing the highest quality of care and services to the elderly, in accordance with, or exceeding all applicable local, state and/or federal laws/mandates regarding the operation of a Long-Term Care Facility in Pennsylvania. Representative entities of Holy Family Manor will evidentially substantiate compliance with all applicable local, state, and/or federal laws/mandates regarding operation of a Long-Term Care Facility in Commonwealth of Pennsylvania during the survey conducted subsequent to that concluded on February 06, 2023.

Unit manager will audit the charts for proper medication administration for three medication administration passes. Education was provided by DON/ADON to all staff with five rights of medication administration when the deficiency was found on 2/6/24. LPN (Licensed Practical Nurse) who made a medication error received Corrective Action related to not following the five rights of medication administration. The facility will extend orientation with the LPN for med pass until audited by three different unit managers. Unit managers from different units will conduct a medication administration audit on different floors and with all newly hired nurses as part of orientation requirements. Weekly checks for one month by the unit managers to make sure all residents have proper identification on their person and the room i.e, name and room number. All new onboarding nurses will have a med-pass audit done by three different managers to pass the med audit competency check list. Staff will be educated on utilizing three different methods of patient identification prior to administering medication(s). DON will monitor medication errors monthly for twelve months. DON will report the audit results during the Quality Assurance Performance Improvement meeting. Inter Disciplinary Team will review any residents with the same initials and place them in the appropriate rooms to minimize any potential error from occurring due to the same initials. Corrective action will be completed by 02/17/24.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port