Pennsylvania Department of Health
EMBASSY OF HUNTINGDON PARK
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


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EMBASSY OF HUNTINGDON PARK
Inspection Results For:

There are 105 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.


EMBASSY OF HUNTINGDON PARK - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on May 21, 2024, it was determined that Embassy of Huntington Park 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:

483.70(q)(1)-(5) REQUIREMENT Payroll Based Journal:

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.

§483.70(q) Mandatory submission of staffing information based on payroll data in a uniform format.
Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

§483.70(q)(1) Direct Care Staff.
Direct Care Staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Direct care staff does not include individuals whose primary duty is maintaining the physical environment of the long term care facility (for example, housekeeping).

§483.70(q)(2) Submission requirements.
The facility must electronically submit to CMS complete and accurate direct care staffing information, including the following:
(i) The category of work for each person on direct care staff (including, but not limited to, whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS);
(ii) Resident census data; and
(iii) Information on direct care staff turnover and tenure, and on the hours of care provided by each category of staff per resident per day (including, but not limited to, start date, end date (as applicable), and hours worked for each individual).

§483.70(q)(3) Distinguishing employee from agency and contract staff.
When reporting information about direct care staff, the facility must specify whether the individual is an employee of the facility, or is engaged by the facility under contract or through an agency.

§483.70(q)(4) Data format.
The facility must submit direct care staffing information in the uniform format specified by CMS.

§483.70(q)(5) Submission schedule.
The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly.

Observations:

Based on facility requirements according to the Affordable Care Act (ACA), review of Payroll Based Journal (PBJ) Staffing Data Reports, and staff interviews, it was determined that the facility failed to electronically submit direct care staffing information for one of four quarters reviewed (fiscal year quarter one 2024).

Findings include:

Review of Section 6106 of the ACA requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data to the Centers for Medicare and Medicaid Services (CMS). Submission must be received by the end of the 45th calendar day (11:59 p.m. Eastern Standard Time) after the last day of each fiscal quarter to be considered timely.

First quarter reporting includes data from October 1st through December 31st and is due by February 14th. Second quarter reporting includes data from January 1st through March 31st and is due by May 15th. Third quarter reporting includes data from April 1st through June 30th and is due by August 14th. Fourth quarter reporting includes July 1st through September 30th and is due by November 14th.

Review of PBJ staffing data reports for fiscal year quarter one 2024 (October 1- December 31) revealed that the facility triggered for "Failed to Submit Data for the Quarter."

Interview with the Nursing Home Administrator on May 21, 2024, at 10:34 a.m. confirmed that the PBJ report for fiscal quarter one for 2024 was not submitted.

28 Pa. Code 201.18(b)(3)Management.

Plan of Correction - To be completed: 06/18/2024

1. Unable to go back and electronically submit direct care staffing information for quarter one of 2024 (October 1 – December 31)
2. Nursing Home Administrator and/or designee will educate staffing coordinator and Human Resource director to ensure they are pulling weekly reports. Pulling weekly reports will assist with ensuring staffing hours are pulling correctly and provide time to correct if needed.
3. Nursing Home Administrator and/or designee will educate staffing coordinator and Human Resource director to ensure they are pulling weekly reports. Pulling weekly reports will assist with ensuring staffing hours are pulling correctly and provide time to correct if needed.
4. Nursing Home administrator and/or designee will audit monthly to ensure payroll-based journal reporting is completed timely. Monthly audits will be completed x 3 months.
Results of the audits will be reported to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after initial audits are reported to ensure that the deficiency is corrected.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

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) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for three of 29 residents reviewed (Residents 28, 39, 75).

Findings include:

The facility's policy regarding care plans, dated April 16, 2024, indicated the comprehensive care plan will be reviewed and revised as necessary, when a resident experiences a status change. The care plan will be updated with the new or modified interventions.

An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 28, dated March 26, 2024, revealed that the resident was understood, able to understand what was being said, required assistance with care needs, had an unstageable pressure ulcer to sacrum, received intravenous therapy (administration of fluids and/or medications directly into a person's vein), and received an antibiotic. A care plan for Resident 28, dated March 22, 2024, revealed that the resident had a midline (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications) and was receiving an antibiotic.

A nursing note, dated May 3, 2024, at 1:50 a.m. revealed that Resident 28's midline and antibiotic were discontinued; however, as of May 20, 2024, the care plan was not updated or resolved.

Interview with the Nursing Home Administrator on May 20, 2024, at 3:09 p.m. confirmed that Resident 28's midline and the antibiotic were discontinued and that the care plan for the midline and antibiotic should have been resolved and it was not.

An admission MDS assessment for Resident 39, dated April 11, 2024, revealed that the resident was understood, able to understand what was being said, required assistance with care needs, had a diabetic foot ulcer and a surgical wound, received intravenous therapy, and had diagnoses including multidrug resistant organism (MDRO) (a germ that is resistant to many antibiotics making treatment difficult) and osteomyelitis (infection of the bone) of left ankle and foot.

A nursing note, dated April 23, 2024, at 8:27 a.m. revealed that Resident 39's contact isolation precautions were discontinued and the antibiotic therapy was completed. Enhanced barrier precautions were ordered.

A care plan for Resident 39, dated April 5, 2024, revealed that the resident was on isolation/quarantine precautions for Methicillin-resistant Staphylococcus aureus (MRSA) (type of staph bacteria resistant to many antibiotics making treatment difficult) and Vancomycin-resistant Enterococcus (VRE) (bacteria resistant to the antibiotic vancomycin) with an intervention to discontinue precautions as soon as the infection no longer exists.

Interview with the Nursing Home Administrator on May 21, 2024, at 12:57 p.m. confirmed that Resident 39's care plan for isolation/quarantine precautions for MRSA and VRE should have been resolved and it was not.

A nursing note, dated May 11, 2024, at 12:42 a.m., revealed that Resident 75 was admitted to the facility with a wound vac (treatment that uses pressure to help close wounds and increase healing) to her right knee.

Physician's orders, dated May 11, 2024, included orders for the wound vac dressing to be changed every Monday, Wednesday, and Friday and the negative pressure setting be 150 mmHg (millimeters of mercury) continuously.

Resident 75's current care plan indicated that the resident had skin impairments and treatments were to be provided as ordered; however, there was no documented evidence that Resident 75's care plan was revised to reflect the need for a wound vac to the right knee.

Interview with the Nursing Home Administrator on May 21, 2024, at 11:41 a.m. confirmed that Resident 75's care plan was not updated to include Resident 75's need for a wound vac to the right knee.

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

Plan of Correction - To be completed: 06/18/2024

1. Resident # 28,39,75 care plans updated to reflect changes in residents' care needs.
2. Licensed practical Nurse assessment coordinator (LPNAC) and/or designee will pull two week look back of new orders/discontinued orders to be sure care plans are updated to reflect changes in resident care needs.
3. LPNAC and/or designee will educate licensed nurses on facility's policy regarding care plans.
LPNAC and/or designee will educate licensed nurses on updating care plans with new or modified orders/interventions
4. Assistant Director of Nursing (ADON) and/or designee will audit resident orders (active and discontinued) to reflect changes in resident care needs weekly x 4.
Results of the audits will be reported to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after initial audits are reported to ensure that the deficiency is corrected.
.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§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 facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that ice was prepared and stored under sanitary conditions in one of two ice machines observed, and failed to ensure that food in the main kitchen was stored in accordance with professional standards for food service safety.

Findings include:

The facility policy for cleaning the ice machines and ice storage containers, dated April 16, 2024, indicated that all ice machines will be cleaned monthly, at a minimum, with approved sanitizing agent.

Observations of the second-floor ice machine on the May 21, 2024, at 8:20 a.m. revealed a dark, removable substance on the inside of the ice machine in the area where water flows and ice is dispensed.

Interview with the Assistant Maintenance Director on May 21, 2024, at 1:51 p.m. confirmed that the ice machine had a dark, removable substance inside the ice machine. He stated that he had cleaned the first-floor ice machine at the beginning of the month and that the machine on the second floor was overdue to be cleaned.

Cleaning schedules provided by the Assistant Maintenance Director on May 21, 2024, at 2:03 p.m. confirmed that the first-floor ice machine was cleaned on May 10, 2024. There was no documented evidence to indicate that the second-floor ice machine had been cleaned for the month of May.

Interview with the Nursing Home Administrator on May 21, 2024, at 2:33 p.m. confirmed that there was no documented evidence to indicate that the second-floor ice machine had been cleaned for the month of May.

The facility policy regarding food storage, dated April 16, 2024, revealed that all foods stored under refrigeration or freezer must be stored in the proper order based on standard Hazard Analysis Critical Control Point (HACCP) guidelines for refrigeration and freezer storage.

Observations in the kitchen's main walk-in refrigerator on May 18, 2024, at 9:40 a.m. revealed a large brick of cheese, dated May 17, 2024, that was unsealed and open to air. Observations in the kitchen's main preparation area revealed a large container of brown rice, covered with plastic wrap, dated with an expiration date of February 2022.

Interview with the Dietary Manager on May 18, 2024, at the time of observation, confirmed that the cheese should have been sealed and not open to air and that the expired rice should have been discarded.

28 Pa. Code 211.6(f) Dietary Services.

28 Pa. Code 207.4 Ice Containers and Storage.

Plan of Correction - To be completed: 06/18/2024

1. A) Ice storage container on 2nd floor was thoroughly cleaned with approved sanitizing agent and no longer has the dark removable substance.
B) Unsealed large brick of cheese was discarded on May 18th, 2024. A large container of brown rice with expiration date of February 2022 was discarded 5/18/2024.
2. A) Only one other ice storage container on 1st floor and it was observed and documented to be cleaned.
B) No other items noted to be expired or outdated with observation of surveyors throughout their time here for survey.
3. A) Administrator and /or designee will educate maintenance on proper cleaning of ice machines and on facility policy for cleaning of ice machines. Oversight by Maintenance director to ensure cleaning is properly completed. Education to staff to ensure they are reporting to maintenance if they see any cleanliness issues that needs addressed.
B) Dietary manager and/or designee will educate dietary staff on ensuring proper food storage in accordance with professional standards for food service safety. Supervisor will inspect storerooms, coolers, and freezer daily to ensure proper storage and dating of items.
4. A) Maintenance and/or designee will complete random audits weekly of ice machines to ensure cleaned and no debri or substance located on them.
B) Dietary manager and/or designee will complete random daily spot checks of refrigerators/walk in coolers to ensure all items are properly stored and dated weekly x 4. Results of the audits will be reported to the facility's Quality Assurance Steering Committee.
The Quality Assurance Steering Committee will determine the frequency of the audits after initial audits are reported to ensure that the deficiency is corrected.

483.25(h) REQUIREMENT Parenteral/IV Fluids:

§ 483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.

Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to flush an intravenous (IV) line and to change an intravenous line dressing and caps (caps that disinfect IV ports) as ordered by the physician for one of 29 residents reviewed (Resident 48).

Findings include:

The facility's policy regarding intravenous (IV) catheters (a tube placed in a vein that can be used to deliver fluids and/or medications), dated September 17, 2019, revealed that when a resident was ordered intravenous medication, a 10 milliliter (ml) saline flush (a method used to clean a catheter of blood or medication) was to be administered before and after each medication that was infused.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 48, dated April 7, 2024, indicated that the resident was cognitively intact and received IV medications.

A nursing note, dated April 1, 2024, at 11:15 a.m., revealed that Resident 48 was admitted to the facility and had a double lumen (two ports) PowerHickman midline (a catheter that is placed in a peripheral vein for long-term administration of fluids and/or medication) present in the right chest.

Physician's orders, dated April 4, 5, and 15, 2024, included orders for resident's central line be flushed with 5-10 mL of saline before and after medication administration, a maintenance flush every shift, and to administer 750 milligrams (mg) of levofloxacin (antibiotic) intravenously for 10 administrations related to a MRSA (Methicillin Resistant Staphylococcus Aureus - drug resistant organism) infection.

Resident 48's Medication Administration Record (MAR) for April 2024 revealed that the resident received 750 mg of levofloxacin on April 2 to 11, 2024, at 8:00 a.m.; however, there was no documented evidence that Resident 48's midline was flushed before and after the administration of levofloxacin on April 2 to 4, 2024. There was also no documented evidence that the resident's intravenous line dressing and caps were changed as ordered on May 3 and 10, 2024, or that the midline was flushed with 5-10 mL of saline every shift on April 14, 16, 18 ,and 22, and May 2 and 10, 2024.

Interview with the Nursing Home Administrator on May 21, 2024, at 12:57 p.m. confirmed that there was no documented evidence that Resident 48's midline line dressings and caps were changed as ordered, that the midline was flushed every shift with saline, or that the midline was flushed before and after the administration of levofloxacin on the dates mentioned above.

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

Plan of Correction - To be completed: 06/18/2024

1. Unable to go back and do late charting for intravenous line dressing and caps a ordered by physician for dates noted during survey missed for resident # 48. Staff that worked these dates that are still employed will be educated to ensure medication administration record is completed. Doctor notified of missed entries. Resident #48 Intravenous line was discontinued on 5/28/2024.
2. Director of Nursing and/or designee will pull order listing for any resident that has Intravenous access to ensure that line is flushed, dressing and caps are changed as per physician orders for past 30 days.
3. Staffing educator and/or designee will educate licensed nursing staff on policy for intravenous catheters
Staffing educator and/or designee will educate licensed nursing staff on proper completion and signing off orders on medication administration record (MAR) for intravenous lines as ordered
4. Infection control nurse and/or designee will complete random audits of resident(s) with intravenous line to ensure proper completion and signing off orders on medication administration record (MAR)
Results of the audits will be reported to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after initial audits are reported to ensure that the deficiency is corrected.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

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.

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide appropriate services to maintain personal grooming and hygiene for one of 29 residents reviewed (Resident 13) who was dependent for care.

Findings include:

The facility's policy regarding personal care, dated April 16, 2024, revealed that nail care cleaning and trimming should be completed as needed, unless the resident is a diabetic or has another reason it should not be done. In such cases a nurse or podiatrist (a medical specialist who helps with problems that affect feet or lower legs) will provide care.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated February 19, 2024, revealed that the resident was understood, could understand others, and had diagnoses that included Alzheimer's and dementia. The resident's care plan, dated February 26, 2020, revealed that the resident had an Activities of Daily Living (ADL) self-care performance deficit related to activity intolerance, limited mobility, and required extensive assistance from staff with bathing.

A bathing report for Resident 13, dated May 2024, revealed that the resident was to receive a shower during the evening on Tuesdays and Fridays, and that the resident was last showered on Friday, May 17, 2024, at 3:06 p.m.

Observations of Resident 13 on May 18, 2024, at 12:03 p.m. and May 21, 2024, at 8:32 a.m. and 11:10 a.m. revealed that the resident's fingernails extended beyond the tip of her fingers and had a dark substance underneath them.

Interview with Nurse Aide 1 on May 21, 2024, at 11:10 a.m. confirmed that Resident 13 had a dark substance underneath her fingernails and should have had them cleaned either during her shower or any time before or after when staff observed that these tasks needed done.

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

Plan of Correction - To be completed: 06/18/2024

1. Resident #13 nail care provided 5/21/2024
2. Ambassador(s) and/or designee will complete a review of their residents to ensure that nail care has been completed on each of their residents and residents have no dark substance or debris under nails. If nail care is needed, nail care will be completed by nursing as able. If nursing is not able to complete nail care, resident will be placed on podiatry list for completion.
3. Nursing administration and/or designee will educate nursing staff on personal care policy and nail care cleaning.
4. Ambassador(s) and/or designee will complete random audit of each resident to ensure that nail care is being provided as needed weekly x 4
Results of the audits will be reported to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after initial audits are reported to ensure that the deficiency is corrected.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§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 review of clinical records and facility investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that interventions were in place and functioning to prevent behaviors for one of 29 residents reviewed (Resident 66).

Findings include:

An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 66, dated February 4, 2024, revealed that the resident was understood, was able to understand what was being said, was cognitively intact, had behaviors affecting others, and required assistance with care needs. A care plan for Resident 66, dated January 30, 2024, revealed that the resident was observed displaying sexually inappropriate behavior.

Review of a facility incident report, dated February 29, 2024, revealed that it was reported by staff that Resident 66 had his hand on another resident's genitals over his pants in the hallway. The other resident was removed from the situation and the registered nurse was made aware. It was noted that both residents were in wheelchairs and immediately separated. Resident 66 remained in the hallway for a short period of time before he began attempting to stop other residents from self-propelling down hallway with his wheelchair. Resident 66 was taken to his room. The registered nurse asked Resident 66 why he touched another resident, and he did not answer. No verbal communication was expressed from Resident 66 during the assessment.

Resident 66's care plan related to sexually inappropriate behaviors was revised on February 29, 2024 to include the intervention for a motion alarm to be placed on the resident's door frame. A nursing note for Resident 66, dated February 29, 2024, at 4:11 p.m. revealed that a motion alarm was placed on Resident 66's door.

The care plan was revised again on March 1, 2024. to add the intervention that Resident 66 must be supervised by staff when out of his room.

Observations on May 19, 2024, at 2:59 p.m. revealed Resident 66 was in his room, lying in bed. Upon entering his room, the alarm on his doorway did not sound. Licensed Practical Nurse 2, who was in the hallway outside of the resident's room, was informed that the alarm was not functioning. She checked the alarm and stated it was in the off position and turned it on. She confirmed that the alarm should have been on. Licensed Practical Nurse 2 also revealed that staff should be checking the function of the alarm daily. After the door alarm was turned on, a nurse aide walked into Resident 66's room and the alarm did not sound again. Licensed Practical Nurse 2 and the nurse aide attempted to get the alarm working and it was still not functioning properly. Licensed Practical Nurse 2 stated she would have maintenance look at it.

Interview with the Nursing Home Administrator on May 20, 2024, at 12:02 p.m. confirmed that the motion alarm on Resident 66's door frame should have been functioning properly and also confirmed that there was no documented evidence that the alarm was being monitored for function and placement.

28 Pa. Code 201.14(a) Responsibility of Licensee.

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

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Plan of Correction - To be completed: 06/18/2024

1. Resident #66 sensor alarm to door was checked by maintenance personnel and batteries replaced. Functioning properly. Care plan and task updated to check placement and function Q 4 hours.
2. Director of nursing and/or designee will complete house audit to ensure any sensor alarm on resident door way is functioning properly, turned on and has care plan and task to check placement and function Q 4 hours.
3. Staff educator and/or designee will educate staff on ensuring function of sensor alarm on door is not turned off. Staff educator and/or designee will educate nursing staff on checking to ensure placement and function of alarm is checked Q 4 hours.
4. Registered nursing supervisor and/or designee will audit daily to ensure that sensor alarms are turned on and functioning properly weekly x 4
Results of the audits will be reported to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after initial audits are reported to ensure that the deficiency is corrected.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for two of 29 residents reviewed (Residents 28, 48).

Findings include:

The facility's policy regarding medication administration, dated April 16, 2024, indicated that staff were to sign the Medication Administration Record (MAR) after administering medications and if the medication was a controlled substance, staff were to sign the narcotic book.

An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 28, dated March 26, 2024, revealed that the resident was understood, able to understand what was being said, required assistance with care needs, had an unstageable pressure ulcer to sacrum, and had complaints of pain. A physician's order for Resident 28, dated March 29, 2024, included an order for the resident to receive 2.5 milligrams (mg) of oxycodone (narcotic pain reliever) every six hours as needed for moderate to severe pain.

Resident 28's controlled drug accountability records for April 2024 revealed that staff signed out doses of oxycodone for administration to the resident on April 1 at 8:00 p.m. and April 12 at 2:30 p.m. However, there was no documented evidence in the MAR that the oxycodone was administered to the resident on the dates and times listed.

Interview with the Nursing Home Administrator on May 21, 2024, at 1:56 p.m. confirmed that there was no documented evidence that staff administered the signed-out doses of oxycodone to Resident 28 on the above dates and times.

An admission MDS assessment for Resident 48, dated April 7, 2024, revealed that the resident was alert and oriented, received as-needed pain medications, had pain occasionally, and received an opiod (narcotic pain reliever). Physician's orders for Resident 48, dated May 15, 2024, included an order for the resident to receive 5 mg of oxycodone (narcotic pain reliever) every four hours as needed for moderate to severe pain.

Resident 48's controlled drug accountability records for May 2024 revealed that staff signed out doses of oxycodone for administration to the resident on May 1 at 8:45 p.m., May 5 at 7:45 p.m., May 8 at 6:15 p.m., May 14 at 5:50 a.m., and May 16 at 8:50 a.m.; however, there was no documented evidence in the MAR that the oxycodone was actually administered to the resident on the dates and times listed.

Interview with the Nursing Home Administrator on May 21, 2024, at 12:10 p.m. confirmed that there was no documented evidence that staff administered signed-out doses of oxycodone to Resident 48 on the above dates and times.

28 Pa. Code 211.9(a)(1) Pharmacy Services.

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

Plan of Correction - To be completed: 06/18/2024

1. Unable to complete late charting for missed entries on medication administration record (MAR) for resident # 28 or #48. Employee(s) that are still employed provided corrective action write up for failure to document narcotic on MAR. With interview of resident #28 and #48 both residents state that they have received all controlled medications that they have asked for and they have had no issues with not receiving medications. Employees interviewed and confirmed they administered the medication and forgot to sign off MAR. Doctor notified of missed entries.
2. Director of Nursing and/or designee will complete 2 week look back of active narcotic orders to ensure that narcotics are being signed out on narcotic sheet as well as MAR.
3. Staffing educator and/or designee will educate licensed nursing staff on controlled drug accountability and documentation.
Staffing educator and/or designee will educate licensed nursing staff on facility policy regarding medication administration
4. Director of Nursing and/or designee will complete random checks of signed out narcotics for residents to ensure that licensed nurses are signing off on MAR that they administered the narcotic as ordered weekly x 4. Any noted discrepancy in documentation or lack of evidence of administration will have a investigation to ensure no misappropriation. Results of the audits will be reported to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after initial audits are reported to ensure that the deficiency is corrected.

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities:

§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 review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) surveys ending April 27, 2023, and July 21, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey ending May 21, 2024, identified repeated deficiencies regarding care plan timing and revision, grooming and personal and oral hygiene, and ensuring that the resident's environment remained free from accident hazards.

The facility's plan of correction for a deficiency regarding a failure to update resident care plans, cited during the survey ending April 27, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding updating residents' care plans.

The facility's plans of correction for deficiencies regarding maintaining grooming and personal and oral hygiene, cited during the survey ending April 27, 2023, revealed that audits would be conducted, and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F677, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding grooming and personal and oral hygiene.

The facility's plan of correction for a deficiency regarding a failure to ensure that the resident environment remained free from accident hazards, cited during the surveys ending April 27, 2023, and July 21, 2023, revealed that the facility developed a plan that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulations to ensure that the resident's environment remained free from accident hazards.

Refer to F657, F677, F689.

28 Pa. Code 201.14(a) Responsibility of Licensee.

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

Plan of Correction - To be completed: 06/18/2024

1. Cited deficient practices and plans of correction will be reviewed by the Quality Assurance Improvement Committee for any
Further action needed.
2. All residents have the potential to be affected by the Quality Assurance program at the facility.
3. Administrator and/or designee will re-educate the department head team on Quality Assurance and Performance Improvement including the documents from Centers for Medicare and Medicaid Services related to performance improvement projects
4. The Administrator and/or designee will oversee the next Quality Assurance Steering Committee meeting(s), guiding the team in root cause analysis to determine what approaches or different approaches and/or interventions can be implemented to address the deficient areas noted to ensure plans are effective in improving the delivery of care and services effectively to prevent recurring deficiencies.
Results of the audits will be reported to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after initial audits are reported to ensure that the deficiency is corrected.

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