Pennsylvania Department of Health
HAVEN PLACE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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HAVEN PLACE - 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 June 10, 2024, at Haven Place, it was determined that there were no federal deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care; however, the facility was not in compliance with 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(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 staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents on five of 21 evening shifts reviewed; and failed to ensure a minimum of one nurse aide per 20 residents on one of 21 overnight shifts reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following nurse aides (NA) scheduled for the resident census:

Evening shift:

May 16, 2024, 5.75 NAs for a census of 76, requires 6.33 NAs.
May 17, 2024, 6.25 NAs for a census of 77, requires 6.42 NAs.
May 18, 2024, 5.00 NAs for a census of 77, requires 6.42 NAs.
May 19, 2024, 5.75 NAs for a census of 76, requires 6.33 NAs.
May 20, 2024, 6.0 NAs for a census of 75, requires 6.25 NAs.

Overnight shift:

June 4, 2024, 3.13 NAs for a census of 74, requires 3.70 NAs.

This surveyor reviewed this information during an interview with the Nursing Home Administrator on June 10, 2024, at 11:10 AM.

Plan of Correction - To be completed: 06/24/2024

Facility ensures that sufficient personnel are provided on a 24-hour basis to provide nursing care to meet the needs of all residents.

Facility designee will continue to recruit and retain certified nursing assistant (CNA) staff through utilizing recruitment fairs, engagement events and visiting community career centers.

Education given to staff responsible for regulation P5510. Ongoing/reoccurring meetings with facility recruiting will take place.

Facility designee will conduct random audits to review certified nursing assistant (CNA) schedule for regulation P5510 x3 months.

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.

§ 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 review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse per 25 residents during the day on one of 21 day shifts reviewed and a minimum of one licensed practical nurse per 30 residents on two of 21 evening shifts reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following licensed practical nurse (LPN) scheduled for the following resident census:

Day shift:

May 12, 2024, 3.0 LPNs for a census of 76, requires 3.04 LPNs.

Evening shift:

May 11, 2024, 2.50 LPNs for a census of 76, requires 2.53 LPNs.
May 19, 2024, 2.50 LPNs for a census of 77, requires 2.57 LPNs.

This surveyor reviewed this information during an interview with the Nursing Home Administrator on June 10, 2024, at 11:10 AM.

Plan of Correction - To be completed: 06/24/2024

Facility ensures that sufficient personnel are provided on a 24-hour basis to provide nursing care to meet the needs of all residents.

Facility designee will continue to recruit and retain licensed practical nurse (LPN) staff through utilizing recruitment fairs, engagement events and visiting community career centers.

Education given to staff responsible for regulation P5530. Ongoing/reoccurring meetings with facility recruiting will take place.

Facility designee will conduct random audits to review licensed practical nurse (LPN) schedule for regulation P5530 x3 months.

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.

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