Pennsylvania Department of Health
HRH TRANSITIONAL CARE UNIT (A D/B/A ENTITY OF HRHS)
Patient Care Inspection Results

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HRH TRANSITIONAL CARE UNIT (A D/B/A ENTITY OF HRHS)
Inspection Results For:

There are  37 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.
HRH TRANSITIONAL CARE UNIT (A D/B/A ENTITY OF HRHS) - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare Recertification survey, State Licensure survey, and Civil Rights survey completed on March 7, 2024, at HRH Transitional Care Unit (a D/B/A Entity of HRHS), it was determined there were no deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as it related to the Health portion of the survey process; however, the facility was not in compliance with the following requirements of 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.






 Plan of Correction:


211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 12 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from October 8 to 14, 2023, December 26, 2023, to January 1, 2024, and February 29 to March 6, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on day shift (7:00 a.m. to 3:00 p.m.) on October 8, 2023.

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on evening shift (3:00 p.m. to 11:00 p.m.) on October 8 and 12, December 28, 29, 30 and 31, 2023, and on January 1, February 29, March 1, 4, and 5, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 20 residents on night shift (11:00 p.m. to 7:00 a.m.) on December 30. 2023, January 1 and March 3, 2024.





 Plan of Correction - To be completed: 03/29/2024

Holy Redeemer TCU has always maintained 5-star staffing levels regarding HPPD far above the state minimums therefore no negative impact or poor clinical outcomes occurred for any patients on the unit due to the staffing ratios. TCU will work closely with our staffing team to assure we meet the NA ratio on each shift. A staffing grid was created to assist the schedulers to know how many of each type of staff they must place on the schedule for each day. TCU team will complete the DOH staffing calculator, for one month and then randomly to assure compliance.

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