Pennsylvania Department of Health
NORTHAMPTON POST ACUTE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

NORTHAMPTON POST ACUTE
Inspection Results For:

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NORTHAMPTON POST ACUTE - 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 May 31, 2024, it was determined that Northampton Post Acute 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 Licensure Regulations.

Plan of Correction:

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

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.

§483.60(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 observation, it was determined that the facility failed to prepare and serve food under sanitary conditions in the kitchen.

Findings include:

Observation of the tray line service on May 29, 2024, at 11:22 a.m., revealed the following:

There was uncooked beef on the floor and shelf under a food preparation table. There were clean cutting boards, and bins of food product that included flour and powdered mashed potatoes on that shelf. Dietary Employee 2 (DE 2) was observed preparing resident meal trays. DE 2 proceeded to turn away from the tray line and obtained food items from the oven on multiple occasions. DE 2 then returned to the tray line and continued handling resident plates and ready to eat food items, without changing gloves or performing hand hygiene.

CFR 483.60 Food Procurement Store/Prepare/Serve-Sanitary.
Previously cited 7/18/23.

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

28 Pa. Code 207.2(a) Administrator's responsibility.

Plan of Correction - To be completed: 06/19/2024

1. No cited residents.
2. The uncooked beef was disposed of and the shelf was cleaned on 5/29/2024.
3. Dietary staff will be re-educated on the policy for hand hygiene, glove usage, and food storage.
4. The Dietary manager/designee will conduct random weekly observations of the tray line with a focus on food handling and hand hygiene. Trends will be reported to the Quality Assurance Performance Improvement committee for further action planning as needed. Further audit frequency will be determined based on prior audit findings.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

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.

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Observations:
Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess a significant weight change for one of seven sampled residents at risk for weight loss. (Resident 100)

Findings include:

A review of the facility policy entitled, "Nutritional Assessment," last reviewed January 1, 2024, revealed that staff would conduct a nutritional assessment as indicated by a change in condition that placed the resident as risk for impaired nutrition.

Clinical record review revealed that Resident 100 had diagnoses that included dementia and depression. Review of the care plan revealed that the resident was at risk for a nutritional problem. On September 12, 2023, the resident weighed 142.4 pounds (lbs.). On October 6, 2023, the resident weighed 129.6 lbs., which reflected a significant weight loss of 8.9 percent in less than 30 days. On October 9, 2023, the resident weighed 129.4 lbs., which confirmed the weight loss. There was no evidence that the dietitian assessed the resident until February 16, 2024.

In an interview on May 30, 2024, at 3:17 p.m., the Administrator confirmed that the resident was not assessed by the dietitian prior to February 16, 2024.

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

Plan of Correction - To be completed: 06/19/2024

1. R100 has been evaluated by the dietitian.
2. Current residents' weight values will be reviewed to identify those who are triggering a significant weight loss over 30 days. Variances will be addressed by the dietitian and documented accordingly.
3. The dietitian will be re-educated by the Director of Nursing / Designee on the policy for weight management.
4. The Administrator/designee will conduct random weekly audits for 4 weeks of residents identified with a significant weight loss in 30 days to validate dietitian documentation has been completed. Trends will be reported to the Quality Assurance Performance Improvement committee for further action planning as needed. Further audit frequency will be determined based on prior audit findings.

483.25(l) REQUIREMENT Dialysis:

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide services consistent with professional standards of practice for one of three residents receiving dialysis. (Resident 125)

Findings include:

Review of the facility policy entitled, "Nursing Home Dialysis Transfer Agreement," last reviewed January 1, 2024, revealed that the facility would ensure that appropriate medical, social, administrative, and other information would have accompanied all designated residents at the time of the transfer to the dialysis center. The information was to include appropriate medical records that included history of illness, treatment that was presently being provided to the resident (including medications), any changes in condition, medication, diet, or fluid intake.

Clinical record review revealed that Resident 125 had diagnoses that included end stage renal disease that required hemodialysis and anemia. Review of the resident's dialysis communication forms revealed that section one of the form, which was to be completed prior to transfer and included medications, vital signs, and status of the shunt site (point of access for dialysis), was not completed on April 2, 4, 16, 18, 20, 23, 25, and 30, 2024, and May 14, 16, 21, 23, 25, 28, and 30, 2024.

In an interview on May 30, 2024, at 3:17 p.m., the Administrator confirmed that the communication forms should have been completed prior to the resident's transfer to dialysis on the identified dates.

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

Plan of Correction - To be completed: 06/19/2024

1. R125's dialysis communication form is being completed prior to transfer to dialysis.
2. Current residents who are receiving Hemodialysis will be reviewed for utilization of the dialysis communication form. Variances will be addressed and recorded on the facility tool.
3. Licensed nursing staff will be re-educated by the Director of Nursing / Designee on the dialysis communication forms and nursing documentation.
4. The Director of Nursing/Designee will conduct random weekly audits for 4 weeks of residents who are receiving hemodialysis to review completion of the dialysis communication form. Trends will be reported to the QAPI committee for further action planning as needed. Further audit frequency will be determined based on prior audit findings.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratio for one of 21 days reviewed.

Findings include:

Review of nursing schedules from May 9 through 29, 2024, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on day (7:00 a.m. to 3:00 p.m.) shift on May 12, 2024.

Plan of Correction - To be completed: 06/19/2024

1. No cited residents.
2. Facility will review nursing schedules and ratios during the daily staffing meetings for Licensed Practical Nurses. A variety of methods for staffing and recruitment will be utilized in order to fill vacant positions. Methods will be reviewed for effectiveness during daily staffing review and adjusted according to facility need.
3. The Administrator / Designee will re-educate the staffing coordinator on the policy regarding staffing, schedules, and ratios for Licensed Practical Nurses.
4. The Administrator / Designee will audit the nursing schedule ratios 5 times per week for 2 weeks, then weekly for 4 weeks. Results of audits will be submitted to the Quality Assurance Performance Improvement committee for further action planning as needed. Further audit frequency will be determined based on prior audit findings

§ 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 2.87 hours of direct care for each resident for two of 21 days reviewed.

Findings include:

Review of nursing schedules from May 9 through 29, 2024, revealed that following total nursing care hours below minimum requirements:

May 11, 2024: 2.83 care hours per resident.

May 12, 2024: 2.67 care hours per resident.

Plan of Correction - To be completed: 06/19/2024

1. No cited residents
2. Facility will review nursing schedules and PPD's during the daily staffing meetings for nursing staff. A variety of methods for staffing and recruitment will be utilized in order to fill vacant positions. Methods will be reviewed for effectiveness during daily staffing review and adjusted according to facility need.
3. The Administrator / Designee will re-educate the staffing coordinator on the policy regarding staffing, schedules, and PPD minimums for Nursing staff.
4. The Administrator / Designee will audit schedule PPD's 5 times per week for 2 weeks, then weekly for 4 weeks. Results of audits will be submitted to the Quality Assurance Performance Improvement committee for further action planning as needed. Further audit frequency will be determined based on prior audit findings

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