Pennsylvania Department of Health
 ELIZABETHTOWN NURSING AND REHABILITATION
Patient Care Inspection Results

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ELIZABETHTOWN NURSING AND REHABILITATION
Inspection Results For:

There are  132 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.
ELIZABETHTOWN NURSING AND REHABILITATION - 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 survey completed on July 18, 2024, it was determined that Elizabethtown Nursing and Rehabilitation Center 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:


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on staff interview and facility policy review, it was determined the facility failed to maintain a data collection system of surveillance for 10 of 12 months reviewed (October 2023, November 2023, December 2023, January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, and July 2024).

Findings include:

Review of the facility policy, titled "Infection Control", last reviewed June 2024, revealed the facility will maintain a monthly line list of residents with infections for trending and outbreak potential, follow-up review of lab data is compared, and a monthly review is completed to identify trends to facilitate infection control surveillance. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and health-care associated infections, to guide appropriate interventions and required reporting, and to prevent future infections.

The facility's monthly infection control logs for October 2023 through July 2024 were unable to be provided by the facility. The infection control log book had data entered for July 2023, August 2023, and September 2023, but the rest of the pages for October 2023 through July 2024 were blank.

During an interview with the Nursing Home Administrator (NHA) on July 18, 2024 at 11:00 AM, the NHA confirmed the monthly infection control line list data should be maintained but was not being completed because the facility does not have an Infection Preventionist currently trained or credentialed.

28 Pa Code 201.14(a)(c)Responsibility of licensee
28 Pa Code 211.1(a)(c)Reportable diseases



 Plan of Correction - To be completed: 08/14/2024

The facility has developed and initiated line listings and infection control logs for existing residents and staff as appropriate that have an active infection to ensure proper surveillance, tracking, trending, outbreak management and reporting of infections in accordance to the facility's infection control program. The facility has identified an Infection Preventionist in the facility who meets qualifications to function in this role and is certified in Infection Prevention.

The Infection Preventionist/designee will conduct a facility wide audit of current residents and staff as appropriate that have an active infection to ensure tracking logs and line listings have been initiated to facilitate proper surveillance, tracking, trending, outbreak management and reporting of infections in accordance with the facility's infection control program.

Director of Nursing will educate licensed nursing staff, Infection Preventionist and all appropriate personnel on Ftag 880 and the importance of ensuring the facility has an effective infection control program that includes an identified Infection Preventionist, proper tracking of infections with use of line listings, policies an procedures and ongoing prevention, management and reporting of infections.

Infection Preventionist/designee will audit residents with current infections to ensure there is proper identification, tracking, management and reporting of infections to include use of line listings. These audits will be conducted weekly for four weeks and monthly for two months. Results of these audits will be reviewed through the Quality Assurance Performance Improvement Committee for additional recommendations as necessary.

483.80(b)(1)-(4) REQUIREMENT Infection Preventionist Qualifications/Role: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.
§483.80(b) Infection preventionist
The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must:

§483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;

§483.80(b)(2) Be qualified by education, training, experience or certification;

§483.80(b)(3) Work at least part-time at the facility; and

§483.80(b)(4) Have completed specialized training in infection prevention and control.
Observations:

Based on staff interviews and state regulations, it was determined that the facility failed to have an Infection Preventionist (IP) that completed an approved program for specialized training in infection prevention and control.

Findings include:

The Centers for Medicare and Medicaid Services regulation stated, "The facility must designate one or more individual(s) as the Infection Preventionist(s) (IP(s) who are responsible for the facility's IPCP (Infection Prevention Control Program) that have completed specialized training in infection prevention and control."

During an interview with the Director of Nursing (DON) on July 15, 2024, at 10:00 AM, Employee 4's (Registered Nurse) IP credentials were requested. The DON confirmed Employee 4 is currently doing the modules that are required to obtain certification for the IP position. The DON also informed the surveyor that no Infection Control data has been tracked since September 2023.

28 Pa. Code 201.18(b)(2) Management


 Plan of Correction - To be completed: 08/14/2024

The Facility has identified an Infection Preventionist that meets the required qualifications including but not limited to certified in infection preventionist, manages the facility's Infection Control program and is a member of the Quality Assurance Committee.

The Director of Nursing/designee will educate the Infection Preventionist on Ftag 882 and the requirements to ensure a qualified Infection Preventionist is identified and designated as the Infection Preventionist and manages the facility's infection Prevention Program.

The Director of Nursing/designee will perform audits to ensure that the identified Infection Preventionist maintains appropriate qualifications to meet the requirements as the Infection Preventionist and effectively manages the Infection Control Program these audits will be conducted monthly for two months and quarterly as part of the Infection Control Committee review. Results of these audits will be reviewed through the Quality Assurance Performance Improvement Committee for additional recommendations as necessary.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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.
§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:

Based on facility policy review, clinical record reviews, and staff interview, it was determined that the facility failed to offer the option to formulate an advance directive, as evidenced by utilization of only the POLST (Pennsylvania Orders for Life-Sustaining Treatment) and no documentation of the resident's choices pertaining to advanced directives or documenting how the resident was informed of his or her right to develop a living will or advance directive for four of 35 records reviewed (Residents 1, 20, 33, and 45).

Findings include:

The facility's admission packet referring to the advance directive section stated, "... if the resident has a health care directive, he or she must provide a valid executed original advance directive to the Nursing Home Administrator (NHA)." There is no indication that residents are offered the opportunity to formulate an advance directive.

A review of Resident 1's clinical record failed to include a discussion regarding the opportunity to formulate an Advance Directive. There was no Advance Directive/Living Will present in the clinical record.

A review of Resident 20's clinical record failed to include a discussion regarding the opportunity to formulate an Advance Directive. There was no Advance Directive/Living Will present in the clinical record.

A review of Resident 33's clinical record failed to include a discussion regarding the opportunity to formulate an Advance Directive. There was no Advance Directive/Living Will present in the clinical record.

A review of Resident 45's clinical record failed to include a discussion regarding the opportunity to formulate an Advance Directive. There was no Advance Directive/Living Will present in the clinical record.

An interview with the NHA and Director of Nursing on July 18, 2024, at 9:30 AM, revealed the facility was unable to locate any additional documentation of those Residents being offered information regarding the formulation of an Advance Directive or Living Will at the time of admission or during their stay.

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


 Plan of Correction - To be completed: 08/14/2024

Residents 1, 20, 33 and 45 or their responsible party as appropriate will be informed of their right to formulate an advance directive or living will, offer them the opportunity to do so. The facility will document how the residents were informed of his or her right to develop a living will or advance directive as well as their response.

Director of Nursing/designee will complete a facility wide baseline audit of current residents to ensure they were informed of their right and given the opportunity to formulate an advance directive or living will and documentation indicating on how they were informed of their right and their response.

Director of Nursing/designee will educate Director of Social Services and licensed nursing staff on Ftag 578 and the importance of ensuring residents are advised of their right to formulate an advance directive or living will, documentation indicating how they were advised of their right to do so and their response.

The facility will review with all new residents their right to formulate an advance directive or living will as well as offer them the opportunity to do so and subsequently document how the resident was informed of his or her right and their response as part of the nursing admission process.

Director of Nursing/designee will conduct a random sample audit of 5 new residents to ensure documentation in their chart indicates that resident was advised of their right to formulate an advance directive or living will, how they were advised of their right and their response. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for review and further recommendations.
483.80(d)(3)(i)-(vii) REQUIREMENT COVID-19 Immunization: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.
§483.80(d) (3) COVID-19 immunizations. The LTC facility must develop and implement policies and procedures to ensure all the following:
(i) When COVID-19 vaccine is available to the facility, each resident and staff member
is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized;
(ii) Before offering COVID-19 vaccine, all staff members are provided with education
regarding the benefits and risks and potential side effects associated with the vaccine;
(iii) Before offering COVID-19 vaccine, each resident or the resident representative
receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine;
(iv) In situations where COVID-19 vaccination requires multiple doses, the resident,
resident representative, or staff member is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses;
(v) The resident, resident representative, or staff member has the opportunity to accept or refuse a COVID-19 vaccine, and change their decision;
(vi) The resident's medical record includes documentation that indicates, at a minimum,
the following:
(A) That the resident or resident representative was provided education regarding the
benefits and potential risks associated with COVID-19 vaccine; and
(B) Each dose of COVID-19 vaccine administered to the resident; or
(C) If the resident did not receive the COVID-19 vaccine due to medical
contraindications or refusal; and
(vii) The facility maintains documentation related to staff COVID-19 vaccination that
includes at a minimum, the following:
(A) That staff were provided education regarding the benefits and potential risks
associated with COVID-19 vaccine;
(B) Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and
(C) The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Observations:

Based on clinical record review, facility policy, and interview, it was determined that the facility failed to ensure that residents were offered any current COVID-19 vaccinations as required for four of five residents reviewed (Residents 1, 12, 33, and 41).

Findings include:

Review of facility policy for COVID 19, last reviewed June 2024, indicated that before any of the vaccine is received, the resident or their legal representative shall receive information regarding risks and benefits of the vaccine. The policy also revealed that consents and refusals would be documented in the resident's clinical record. The physician will assess the resident for any contraindications to receiving the vaccine.

A review of Resident 1's clinical record on July 18, 2024, confirmed that Resident 1 was admitted to the facility on March 23, 2023. Further review of the clinical record revealed no historical (past) COVID-19 vaccine or any documentation to confirm that the COVID-19 vaccine was offered by the facility since admission. There was no consent or refusal documentation for COVID-19 vaccine in the clinical record.

A review of Resident 12's clinical record on July 18, 2024, confirmed that Resident 12 was admitted to the facility on June 7, 2024. Further review revealed that an historical COVID-19 vaccine was given in 2021, but there was no documentation to confirm that any current COVID-19 vaccine was offered by the facility since admission. Further review of the clinical record revealed no education on risks and benefits, and no offer or refusal documentation was entered into the clinical record.

A review of Resident 33's clinical record on July 18, 2024, confirmed that Resident 33 was admitted to the facility on September 5, 2022. The clinical record revealed Resident 33 refused COVID-19 dose 1. Further review of the clinical record revealed no education on risks and benefits, and no consent or refusal documentation was entered into the clinical record in the nurses' or physician notes.

A review of Resident 41's clinical record on July 18, 2024, confirmed that Resident 41 was admitted to the facility on March 26, 2024. Further review revealed that an historical COVID-19 vaccine was given in 2021, but there was no documentation to confirm that any current COVID-19 vaccine was offered by the facility since admission. Further review of the clinical record revealed no education on risks and benefits, and no consent or refusal documentation was entered into the clinical record.

During an interview with the Director of Nursing on July 18, 2024, at 11:00 AM, she confirmed that there was no documentation of risks or benefits and no documentation of consents and refusals for these Residents, and agreed that policy should be followed.

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



 Plan of Correction - To be completed: 08/14/2024

Residents 1,12,33 and 41 will be offered Covid-19 vaccines and their response will be documented in the clinical record. If any of those residents wish to receive the vaccine consents will be obtained and facility will coordinate with pharmacy to obtain vaccines and administer. If residents refuse the vaccine education will be provided regarding risks and benefits of the Covid-19 vaccine.

Infection Preventionist/designee will conduct a facility wide audit of current residents to identify which residents have not been offered the Covid-19 vaccine and proceed to offer the vaccine to those that have not. For those that wish to receive the vaccine consents will be obtained and facility will coordinate with pharmacy to obtain vaccines and administer. If residents refuse the vaccine education will be provided regarding risks and benefits of the Covid-19 vaccine.

Infection Preventionist/designee will educate licensed nursing staff on Ftag F887and the importance of offering Covid-19 vaccines to all resident, document their response, obtain consent, and coordinate with the pharmacy to obtain and administer the vaccine. If residents refuse the vaccine document the refusal and educate on risks and benefits of the vaccine.

The Infection Preventionist/designee will conduct a sample audit of 5 residents to ensure they have been offered the Covid-19 vaccine documented response, obtained consent, and coordinated with the pharmacy to obtain and administer the vaccine. If residents refused the vaccine documented the refusal and educated on risks and benefits of the vaccine. These audits will be conducted weekly for four weeks and monthly for two months. Results of these audits will be reviewed through the Quality Assurance Performance Improvement Committee for additional recommendations as necessary.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations: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.
§483.80(d) Influenza and pneumococcal immunizations
§483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

§483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
Observations:

Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure that residents were offered influenza and pneumococcal as required for two of five residents reviewed (Residents 33 and 41).

Findings include:

Review of facility policy for influenza, pneumococcal, and COVID 19, last reviewed June 2024, indicated that before any of the vaccine is received, the resident or their legal representative shall receive information regarding risks and benefits of the vaccine. The policy also revealed that consents and refusals would be documented in the resident's clinical record.

A review of Resident 33's clinical record on July 18, 2024, confirmed that Resident 33 was admitted to the facility on September 5, 2022. The clinical record revealed Resident 33 refused the influenza in 2022 and 2023. There was no record of pneumococcal vaccine for Resident 33. Further review of the clinical record revealed no education on risks and benefits, and no consent or refusal documentation was entered into the clinical record in the nurses' or physician notes.

A review of Resident 41's clinical record on July 18, 2024, confirmed that Resident 41 was admitted to the facility on March 26, 2024. There was documentation to confirm that the Resident was offered the influenza vaccine, but did list influenza vaccine was last administered in 2021. Further review of the clinical record revealed no education on risks and benefits, and no consent or refusal documentation was entered into the clinical record.

During an interview with the Director of Nursing on July 18, 2024, at 11:00 AM, she confirmed that there was no documentation of risks or benefits and no documentation of consents and refusals for these Residents, and agreed that policy should be followed.

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


 Plan of Correction - To be completed: 08/14/2024

Unable to retroactively offer resident 33 education regarding risk and benefits for 2022 and 2023 flu vaccination as flu season for the identified timeframe has lapsed. Resident 33 will be reapproached and offered the pneumococcal vaccine and offered education regarding the risk benefits should the resident refuse or consent should he accept. Unable to retroactively offer resident 41 influenza vaccine for 2022 and 2023 as time has lapsed. Resident will be offered influenza vaccine for 2024 and documentation in the clinical record will reflect consent, refusal if resident refuses and risks and benefits of the vaccine.

Director of Nursing/designee will complete a facility wide audit of current residents and their vaccination status including but not limited to Covid, Influenza and Pneumococcal vaccines to identify any missing information such as consents, refusal documentation and education on risks and benefits.

Infection Preventionist/designee will track resident vaccinations post admission to ensure all required documentation is in the resident clinical record including but not limited to type of vaccine offered, consents, refusal documentation and risk and benefits.

Director of Nursing/designee will educate Infection Preventionist, and facility licensed nursing staff on Ftag 883 and the importance of ensuring the resident clinical record reflects vaccination information including type of vaccine offered, consents, refusal documentation and education on risks and benefits.

Infection Preventionist will conduct a random sample audit of 5 residents to ensure clinical record reflects vaccines offered, consents, refusal documentation and risks and benefits. These audits will be conducted weekly for four weeks and monthly for two months. Results of these audits will be reviewed through the Quality Assurance Performance Improvement Committee for additional recommendations as necessary.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program: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.
§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:

Based on a review of clinical records, the facility's infection prevention and control policy, and staff interview, it was determined that the facility failed to maintain an antibiotic stewardship program that includes a system to effectively monitor antibiotic usage as evidenced by two of three residents reviewed (Residents 6 and 23).

Findings include:

A review of the facility policy, titled "Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes", last reviewed June 2024, stated, "antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of resident antibiotic prescribing practices and facility-wide antibiotic stewardship.
The IP (infection preventionist), or designee will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics.
a.Therapy may require further review and possible changes if:
(1)The organism is not susceptible to antibiotic chosen,
(2)The organism is susceptible to antibiotic chosen,
(3)Therapy was ordered for prolonged surgical prophylaxis, or
(4)Therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics.
All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include:
(1)Resident name and medical record number,
(2)Unit and room number,
(3)Date symptoms appeared,
(4)Name of antibiotic,
(5)Start date of antibiotic,
(6)Pathogen identified,
(7)Site of infection,
(8)Date of culture,
(9)Stop date,
(10) Total days of therapy,
(11) Outcome,
(12) Adverse Events."

A review of Resident 6's clinical record revealed that on July 17, 2024, the Nurse Aide reported that the Resident had episodes of incontinence (involuntary loss of urine) and burning during urination. The physician was notified and ordered an urinalysis with culture and sensitivity. The physician also ordered an antibiotic, Cipro 250 mg (milligrams) to be started twice a day for 7 days prior to receiving any urinalysis results.

The facility was unable to provide the urinalysis results on July 18, 2024.

A review of Resident 23's clinical record revealed a urine specimen was collected July 15, 2024. The progress notes indicate there were no bladder issues. The physician orders stated urinalysis with microscopic culture if indicated. The results of the urinalysis revealed no culture was indicated. On July 16, 2024, the physician ordered an antibiotic, Bactrim DS (double strength) one tab twice a day for 7 days. There was no indication documented for use of the antibiotic.

There was no evidence at the time of the survey of a functioning antibiotic stewardship program that included antibiotic use protocols or a system to monitor antibiotic use to prevent unnecessary antibiotic use.

During an interview with the Director of Nursing and Nursing Home Administrator on July 18, 2024, at 11:00 AM, both confirmed that the facility had no IP or antibiotic surveillance tracking form since September 2023.

28 Pa. Code 211.12 (d)(1)(2) Nursing services
28 Pa. Code 211.10 (a) Resident Care Policies



 Plan of Correction - To be completed: 08/14/2024

Unable to retroactively monitor antibiotic usage for resident 6 and resident 23 as resident 6 is no longer on antibiotics and resident 23 has been discharged from the facility.

Infection Preventionist/designee will conduct a facility wide audit of current residents that are receiving antibiotic therapy to ensure they are effectively being monitored and managed following the facility's antibiotic stewardship program guidelines.

The Director of Nursing/designee will educate the Infection Preventionist and licensed nursing staff on Ftag 881 and the importance of effectively monitoring and managing resident antibiotic usage as delineated by the facility's antibiotic stewardship program.

The facility has identified an infection preventionist who is certified in infection prevention to manage the facility's antibiotic stewardship program to include effectively managing resident antibiotic usage.

The Infection Preventionist/designee will audit and track residents who are receiving antibiotics to ensure they are properly managed for antibiotic usage per the antibiotic stewardship program. These audits will be conducted weekly for four weeks and ongoing monthly as part of the facility's Antibiotic Stewardship program. Results of these audits will be reviewed through the Quality Assurance Performance Improvement Committee for additional recommendations as necessary.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
§483.60(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, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen and in one of one nourishment pantries observed and for one of one meal observed.

Findings include:

Review of facility policy, Outside Food, revised July 2023, read, in part, food brought in from outside sources will be labeled with content and date and discarded after 5 days.

Review of facility policy, Food Storage, revised June 6, 2024, read, in part, open items should be labeled with content and open date.

Observation in the kitchen on July 15, 2024, at 9:31 AM, revealed one plastic container with bulk thickener wasn't marked with a label or date.

During an interview with Employee 1 (Director of Dinning), revealed the container should be labeled with contents and date.

Observation at the three-compartment sink on July 15, 2024, at 9:32 AM, the pH test strips were not available.

During an interview with Employee 1, it was revealed that the pH test strips are stored in the office due to the container falling in the water and rendering them useless. It was observed that the test strip expiration date was May 15, 2024. Employee 1 revealed that the facility doesn't have another container of strips, and that the strips shouldn't be expired.

Observation in the nourishment pantry on July 15, 2024, at 9:40 AM, the following items weren't date marked or contained a resident identifier: one gallon of chocolate, vanilla, and strawberry ice cream; a half of turkey and cheddar submarine sandwich date marked July 14th; one plastic container of open sushi; and one plastic container with a meatloaf dinner.

During an interview with Employee 1 on July 15, 2024, at 9:45 AM, it was revealed that staff shouldn't store personal food items in the nourishment pantry, items should contain a resident identifier, and marked with a date.

Observation of tray line service for the lunch meal on July 16, 2024, at 12:05 PM, revealed Employee 3 (Cook) utilized a gloved hand and retrieved a puree plate out of the steamer, unwrapped the plastic wrap from the plate, touched the trash lid to dispose of the plastic wrap, then went back to serving on the tray line touching the corn bread muffins and plate rims with the same gloved hand; without completing hand hygiene.

At 12:10 PM, Employee 3 changed his gloves, without completing hand hygiene.

Additional observation at 12:12 PM, Employee 3 utilized a gloved hand, retrieved a pasta dinner from the steamer, removed plastic wrap, and touched trash lid with gloved hand to dispose of the plastic wrap. He did change his glove on his right hand, utilizing his left hand for assistance, without completing hand hygiene went back to serving on tray line touching the corn bread muffins and plate rims.

During an interview with Employee 1 on July 16, 2024, at 12:25 PM, it was revealed Employee 3 should've changed his gloves and completed hand hygiene after touching the garbage can lid.

During an interview with the Nursing Home Administrator and Director of Nursing on July 17, 2024, at 11:00 AM surveyor discussed food storage and hand hygiene concerns. It was revealed that hand hygiene, including changing gloves, should've occurred. No further information was provided regarding food storage or the expired pH strips.

28 Pa. Code 211.6 Dietary Services



 Plan of Correction - To be completed: 08/14/2024

Director of Dietary will conduct a facility wide baseline audit of nourishment pantries and kitchen to ensure food is stored in accordance with professional standards for food safety, ensure all food including those brought in from the outside are labeled with content, date and discarded after 5 days. Ensure unexpired PH test strips are available for use by the three-compartment sink, no personal food items are stored in nourishment pantries or resident refrigerators or kitchen.

Director of Dietary will perform baseline tray line service audits during three meals to ensure appropriate hand hygiene is performed after removing gloves, no cross contamination occurs when going from clean to dirty surfaces and overall sanitary preparation of food practices are maintained.

The Director of Dietary/designee will provide education to dietary staff on Ftag 812 and the importance of ensuring all food items are appropriately covered, labeled, dated and discarded after 5 days. Ensuring unexpired PH strips are available for use by the three-compartment sink, no personal food items are stored in nourishment pantries or resident refrigerators or kitchen. Appropriate hand hygiene is performed when changing gloves or when going from clean to dirty surfaces.

The Director of Dietary/designee will audit facility pantries and kitchen to ensure food items are covered, labeled and discarded after 5 days, hand hygiene practices during tray line meal services and no personal food items are stored in resident refrigerators or kitchen. These audits will be conducted weekly for four weeks and monthly for two months.

The Director of Dietary/designee will check PH strips monthly to ensure they are available near the three-compartment sink and are not expired.

Results of these audits will be reviewed through the Quality Assurance Performance Improvement Committee for additional recommendations as necessary.

483.10(j)(1)-(4) REQUIREMENT Grievances: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.
§483.10(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:


Based on observation, document review, policy review, and staff interviews, it was determined that the facility failed to make prompt efforts to resolve resident grievances for two of 10 grievances reviewed, and failed to post in prominent locations the contact information of the identified Grievance Official, including the name, business address (mailing and email), and business phone number in one facility area observed (facility bulletin board).

Findings Include:

A review of the facility's policy, titled "Resident and Family Concerns and Grievances Policy and Procedure", dated 2022, defines its purpose as "To provide for the prompt resolution of medical and non-medical grievances while maintaining confidentiality, in accordance with applicable federal and state statutes and regulations."

The policy continued, "The Facility will provide the resident with a written Grievance Decision, which shall include:
a.the date the grievance was received;
b.a summary statement of the resident's grievance;
c.the steps taken to investigate the grievance;
d.a summary of the pertinent findings or conclusions regarding the resident's concern(s);
e.a statement as to whether the grievance was confirmed or not confirmed;
f.any corrective action taken or to be taken by the Facility as a result of the grievance; and
g.the date the written decision was issued."

A review of the facility-provided grievance forms revealed one without a date, filed by a resident requesting to be provided ginger ale.

Continued review of the grievance form revealed, under the section titled "Resolution", revealed no documentation of a staff response to the Resident and the concern presented regarding the request for ginger ale.

A review of an additional facility-provided grievance form dated May 31, 2024, revealed documentation of missing glasses.

Continued review of the grievance form, under the section titled "Resolution", revealed no documentation of the facility's response to the resolution of the grievance.

An interview with the Nursing Home Administrator (NHA) on July 17, 2024, at 1:38 PM, revealed staff will be educated on following the facility's policy regarding grievances and resolution.

An observation of the facility's bulletin board on July 15, 2024, at 11:04 AM, revealed the name of the facility's Grievance Official (Employee 8).

A review of the bulletin board revealed the posting lacked the required contact information for Employee 8 to include the business address (mailing and email) for resident contact.

An interview with the NHA on July 17, 2024, at 1:39 PM, confirmed the Grievance Official information only displayed Employee 8's name and phone number at that time.

28 Pa. Code 201.14 (a) Responsibility of licensee
28 Pa. Code 201.29 (a) Resident Rights



 Plan of Correction - To be completed: 08/14/2024

Unable to retroactively provide resolution to previous grievances. Grievance official contact information has been updated on facility bulletin board to include additional contact information to ensure additional options are offered when reporting grievances. Grievance lock box has been relocated next to facility bulletin board.

Director of Social Service will conduct a facility wide baseline audit of all grievances in the last 30 days to ensure all required responses are included in the grievance forms including but not limited to staff response to grievance and information pertaining to resident's notification of the resolution and their response to resolution provided.

Nursing Home Administrator/designee will educate Director of Social Services and Facility IDT team on Ftag 585 and the importance of ensuring grievances are completed per the facility's established grievance policy including date of grievance, staff's response to the grievance, resident's notification of the resolution and their response to the resolution.

Grievance box will be monitored by grievance officer or designee with grievances addressed to IDT. Written grievance resolutions will be issued to party responsible for submitting grievance.

Director of Social Services will audit received grievances to ensure they are completed as per facility policy to include date of grievance, staff's response to grievance, notification to resident/responsible party of resolution and their response to the resolution. These audits will be conducted weekly for four weeks and monthly for two months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for review and further recommendations.
483.10(g)(5)(i)(ii) REQUIREMENT Required Postings: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.
§483.10(g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives:
(i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and
(ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community.
Observations:

Based on observation and staff interview, it was determined that the facility failed to post, in a form and manner accessible and understandable to residents, a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies, advocacy groups, and a statement that the resident may file a complaint with the State Survey Agency concerning suspected violations of state or federal nursing facility regulations for one area observed (facility bulletin board).

Findings Include:

An observation of the facility's bulletin board, containing information for resident review, on July 15, 2024, at 11:04 AM, revealed no information listing resident advocacy groups, the State agency information, including mailing and email addresses, telephone numbers, and statements regarding the resident's right to file complaints with State and Federal agencies.

An interview with the Nursing Home Administrator, on July 17, 2024, at 1:40 PM, revealed the required information is now posted and accessible for resident review.

28 Pa. Code 201.14 (a) Responsibility of licensee


 Plan of Correction - To be completed: 08/14/2024

On July 17,2024 Nursing Home Administrator ensured all required postings were posted facility's bulletin board. Postings include list of names, addresses (mailing and email) and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long term care facilities, the Office of the State-Long Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advanced directives requirements and requests for information regarding returning to the community.

Nursing Home Administrator/designee will educate Director of Activities and Director of Social Services on Ftag 575 and the importance of ensuring required postings are posted in an area that is visible and available to residents, staff and visitors and ensuring information is up to date.

Director of Activities will perform monthly checks on the day resident council meeting is scheduled to ensure all required information is posted in the designated location, information is up to date and all required postings are accounted for.

Nursing Home Administrator/designee will conduct monthly audits for two months to ensure required postings are in the designated location and contain all of the required information. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for review and further recommendations.
483.10(g)(10)(11) REQUIREMENT Right to Survey Results/Advocate Agency Info: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.
§483.10(g)(10) The resident has the right to-
(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and
(ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.

§483.10(g)(11) The facility must--
(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility.
(ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and
(iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
(iv) The facility shall not make available identifying information about complainants or residents.
Observations:

Based on observations and staff interview, it was determined that the facility failed to ensure its residents the right to examine the results of the most recent survey and that those results are posted in a place readily accessible to its residents for one area observed (facility lobby).

Findings Include:

An observation in the facility's lobby, on July 15, 2024, at 10:32 AM, revealed the facility's survey results book in an area accessible only by using a code to gain entrance and exit.

Observations in resident areas, beyond the locked lobby area, revealed no survey books for resident review in the dining area, the resident common area, the nurses' station, or the designated activities area.

An interview with the Nursing Home Administrator, on July 17, 2024, at 1:38 PM, revealed the facility's survey results book is now accessible in resident areas and confirmed the book should not only be present in the facility's locked area.

28 Pa. Code 201.14 (a) Responsibility of licensee


 Plan of Correction - To be completed: 08/14/2024

On July 17, 2024 Nursing Home Administrator ensured the facility's most recent survey results are located within the nursing unit in a resident care area that is accessible to all residents, staff and visitors.

Nursing Home Administrator/designee will educate Director of Nursing, Receptionist and Director of Activities on Ftag 577 and the importance of ensuring facility survey results are located in an area that is accessible to residents, staff and visitors on the nursing unit.

Facility Receptionist will perform monthly checks to ensure binder containing the most recent survey results is up to date and on the nursing unit in an area that is accessible to residents, staff and visitors.

Nursing Home Administrator/designee will perform monthly audits for two months to ensure binder containing the most recent survey results is up to date and on the nursing unit in an area that is accessible to residents, staff and visitors. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for review and further recommendations.
483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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.
§483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:

Based on document review and staff interviews, it was determined that the facility failed to ensure each resident is periodically informed of any charges for services not covered under Medicare for two of three residents reviewed at the end of a Medicare stay (Residents 1 and 148).

Findings Include:

A review of Resident 1's Skilled Nursing Facility Beneficiary Notification Review form revealed the last covered day of Medicare A coverage on April 30, 2024.

A review of the facility-provided Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage form (SNF-ABN), revealed Resident 1 would no longer receive Medicare covered therapy services after April 30, 2024, and the estimated cost of those non-covered services was not provided to Resident 1 or her responsible party.

A review of Resident 148's Skilled Nursing Facility Beneficiary Notification Review form revealed a last covered day of Medicare A coverage on February 17, 2024.

A review of the facility-provided SNF-ABN form revealed Resident 148 would no longer receive Medicare covered therapy services after February 17, 2024, and the estimated cost of those non-covered services was not provided to Resident 148 or her responsible party.

An interview with the Nursing Home Administrator on July 16, 2024, at 2:02 PM, revealed the facility will begin informing residents of the cost of non-covered services, and confirmed residents and/or their representatives have the right to be informed of those costs.

28 Pa. Code 201.14 (a) Responsibility of licensee



 Plan of Correction - To be completed: 08/14/2024

Unable to retroactively inform resident 1 or their responsible party of the estimated cost of non-covered therapy services back on April 30, 2024. Unable to retroactively provide resident 148 or their responsible party of the estimated cost of non-covered therapy services back on February 17, 2024.

Director of Social Services/designee will complete a facility wide baseline audit of all residents who have been cut from Medicare Part A and remained in the facility of estimated cost of non-covered services received.

Nursing Home Administrator/designee will educate Director of Social Services and MDS coordinator and Business Office Manager on Ftag 582 and the importance of ensuring residents who are cut form Medicare part A services are provided estimated cost of non-covered services.

Director of Social services/designee will review at the weekly Utilization Review Meeting any/all residents that have been cut from Medicare part A and communicate to the team that the resident or their responsible party were provided the estimated cost of non-covered services in collaboration with the Business Office Manager to ensure costs are appropriate and correct.
483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).
Observations:

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to notify the resident/resident representative and the representative of the Office of the State Long-Term Care Ombudsman of resident transfers in writing to include to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman, for two of three resident records reviewed for hospital transfers (Residents 19 and 46 ).

Findings include:

Review of Resident 19's clinical record documented diagnoses that included depression (feelings of severe despondency and dejection), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), hemiparesis left non-dominant side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles), stroke (damage to the brain from interruption of blood supply), and epilepsy (a disorder in which nerve cell activity in the brain is disrupted, causing seizures).

During an interview with Resident 19 on July 15, 2024, at 10:39 AM, it was revealed she was transferred to the hospital in June 2024 for blood in her stool.

Review of Resident 19's clinical record documented that she was transferred to the hospital on June 22, 2024, and returned July 1, 2024.

Further review of the clinical record failed to document the transfer notice was communicated to or provided to the Resident/Resident Representative.

During an interview with the Nursing Home Administrator (NHA) on July 16, 2024, at 2:24 PM, it was revealed that the nurse calls the responsible party to inform of the transfer to the hospital. The Social Worker prints a report of all of the transfers and discharges for the month and sends the report via email to the State Ombudsman's office once a month.

During an interview with the NHA on July 17, 2024, at 1:40 PM, it was confirmed that nursing will call the resident representative to inform of the transfer. It was also revealed there is no paper documentation of the transfer notice to the Resident/Resident Representative or communication to the State Ombudsman, or bed hold notice for Resident 19.

Review of Resident 46's closed clinical record documented that the Resident was transferred to the hospital on May 23, 2024.

Further review of the closed clinical record failed to document the transfer notice was communicated or provided to the Resident/Resident Representative.

During an interview with the NHA on July 16, 2024, at 2:24 PM, it was revealed that the nurse calls the responsible party to inform of the transfer to the hospital. The Social Worker prints a report of all of the transfers and discharges for the month and sends the report via email to the State Ombudsman's office once a month.

During an interview with the NHA on July 17, 2024, at 1:40 PM, it was confirmed that nursing will call the Responsible Party to inform them of the transfer. The NHA revealed there is no paper documentation of the transfer notice to the Resident or the Responsible Party, and no communication to the State Ombudsman.

28 Pa. Code 201.14(a) Responsibility of Licensee



 Plan of Correction - To be completed: 08/14/2024

Unable to retroactively provide transfer notice for residents 19 and 46 or resident representative. Monthly discharge and
transfer reports to the office of the State Long-Term Care Ombudsman have been updated to include residents
transferred to hospital, date of occurrence, and reason of transfer.
Social worker or designee will perform a facility wide audit of current residents transferred out of the facility in the last 30
days to ensure appropriate transfer notices have been provided to resident or their representative as well as notification
to the State Ombudsman.
Nursing Home Administrator or designee will educate facility licensed staff and Director of Social Services on F623
regulation with the importance of providing notice of transfer to resident or their representative at time of transfer and
provide notifications of all transfer/discharge details to the State Ombudsman included in monthly report.
Social Worker or designee will conduct a random sample audit of 5 residents that have been transferred out of the facility
to ensure appropriate transfer notices have been provided to resident or their representative and notifications made to
the state ombudsman. These audits will be conducted weekly for four weeks and monthly for two months. Results of
these audits will be reviewed by the Quality Assurance Performance Improvement Committee for review and further
recommendations.
483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr: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.
§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the resident and resident representative received written notice of the facility bed-hold policy at the time of transfer for one of three resident records reviewed for hospital transfers (Resident 19).

Findings Include:

Review of Resident 19's clinical record documented diagnoses that included depression (feelings of severe despondency and dejection), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), hemiparesis left non-dominant side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles), stroke (damage to the brain from interruption of blood supply), and epilepsy (a disorder in which nerve cell activity in the brain is disrupted, causing seizures).

During an interview with Resident 19 on July 15, 2024, 10:39 AM, it was revealed she was transferred to the hospital in June 2024 for blood in her stool.

Review of Resident 19's clinical record documented that she was transferred to the hospital on June 22, 2024, and the Resident returned July 1, 2024.

Further review of the clinical record failed to document the bed-hold notice was communicated to or provided to the Resident/Resident Representative.

During an interview with the Nursing Home Administrator (NHA) on July 16, 2024, at 1:50 PM, it was revealed that Resident 19, wouldn't have been issued a bed-hold notice because the Resident's payor source at time of transfer was Medicaid and it is an automatic 15-day bed-hold. Surveyor asked when that information would've been reviewed with the Resident/Resident Representative, and he stated he would have to investigate it.

During an interview with the NHA on July 16, 2024, at 2:24 PM, it was revealed that the nurse calls the responsible party (RP) to inform of the transfer to the hospital and ask if they wish to hold the bed. It was further revealed that the Business Office will follow-up with the RP if a bed-hold is requested to discuss the daily rate cost.

During an interview with the Employee 2 (Business Office Manager) on July 17, 2024, at 11:46 AM, it was revealed that Nursing is to complete the bed-hold notice, there is a form. Nursing is to ask the resident or RP if they want a bed-hold a time of transfer, and they should provide the cost of the daily rate at that time. If a family member contacts her regarding wanting a bed-hold, she will discuss the daily rate, otherwise she doesn't follow-up with the transfers.

During an interview with the NHA on July 17, 2024, at 1:40 PM, it was confirmed that nursing will call the resident representative to inform of the transfer, ask if they would like to hold the bed and discuss the daily rate, and if a bed-hold is requested, the bed hold form is completed by the nurse. It was also revealed there is no paper documentation of the transfer notice to the Resident/Resident Representative or communication to the State Ombudsman or bed-hold notice for Resident 19.

28 Pa. Code 201.14(a) Responsibility of Licensee



 Plan of Correction - To be completed: 08/14/2024

Unable to retroactively provide Bed Hold notices at time of transfer or within 24 hours for resident 19 as their transfer to the hospital has exceeded the time frame.

Director of Social Services/designee will conduct a facility wide audit for any residents transferred to the hospital in the last 30 days to ensure appropriate bed hold policy notices have been provided to the resident or their resident representative at time of transfer or within 24 hours if an emergency transfer.
Any residents identified as not having been issued proper bed hold policies will be provided notices.

Administrator/designee will educate facility licensed staff on F625 and the importance of providing bed hold policy at time of transfer or within 24 hours if an emergency transfer.
As part of the clinical meeting review any residents that have been transferred out of the facility will be reviewed to ensure a bed hold policy was issued at time of discharge or within 24 hours in an emergency transfer.

Administrator/designee will conduct a random sample audit of 5 residents transferred to the hospital to ensure bed hold policy was provided at time of transfer or within 24 hours if an emergency. These audits will be conducted weekly for four weeks and monthly for two months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for review and further recommendations.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on observation, clinical record review, policy review, and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for one of three residents receiving oxygen therapy reviewed (Resident 40).

Findings Include:

A review of the facility's policy, titled "Care Planning-Interdisciplinary Team", revised September 2013, read, in part, "Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident."

A review of Resident 40's physician orders revealed diagnoses that included chronic obstructive pulmonary disease (COPD - A group of lung diseases that block airflow and make it difficult to breathe) and muscle weakness.

An observation of Resident 40, on July 15, 2024, at approximately 11:00 AM, revealed the use of an oxygen concentrator while in bed in her room.

A review of Resident 40's interdisciplinary plan of care revealed none developed to address the use of oxygen, goals, and interventions.

An interview with the Director of Nursing on July 18, 2024, at 9:28 AM, revealed the facility had not developed and implemented a care plan specific to Resident 40's oxygen use.

28 Pa. Code 211.5 (f) Medical records
28 Pa. Code 211.12 (d) 5) Nursing services


 Plan of Correction - To be completed: 08/14/2024

Unable to retroactively update resident 40's care plan as resident's oxygen order has been discontinued.

Director of Nursing/designee will conduct a facility wide baseline audit on residents receiving oxygen therapy to ensure a care plan has been formulated to include interventions that address their oxygen use needs.

Director of Nursing/designee will educate licensed nursing staff on Ftag 656 and the importance of ensuring that residents that have a physician's order and require oxygen have a care plan formulated with interventions that address their oxygen use needs.
As part of the clinical meeting review of new orders the IDT team will ensure a care plan is in place addressing oxygen use needs for residents with orders for oxygen use.

Director of Nursing/designee will conduct a random sample audit of residents that have physician orders for oxygen to ensure a care plan has been developed with interventions in place addressing their oxygen use needs. These audits will be conducted weekly for four weeks and monthly for two months. The results of the Director of Nursing's audit will be reviewed monthly at the facility's Quality Assurance and Performance Improvement meeting

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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.
§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards regarding medication and treatment administration for two of 23 residents reviewed (Residents 24 and 40).

Findings Include:

Review of facility policy, Administering Medication, revised April 2019, read, in part, medications are administered in a safe and timely manner and as prescribed. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record (MAR- recording of physician orders being administered or completed) space provided for that drug and dose. The individual administering the medication initial the resident's MAR on the appropriate line after giving each medication and before administering the next one.

Review of Resident 24's clinical record revealed diagnoses that included depression (feelings of severe despondency and dejection), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), and schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms such as depression. Symptoms may include delusions, hallucination, depression, and manic periods of high energy).

Review of Resident 24's July 2024 MAR failed to provide documentation for the following on Saturday July 6th, 2024, and Sunday July 14th, 2024, evening shift (the MAR contained "blanks", lack of documentation): Atorvastatin at bedtime for hyperlipidemia (high blood lipids), start date October 7, 2023; Famotidine at bedtime for Gastroesophageal Reflux Disease (reflux), start date October 7, 2023; Humalog injection (Insulin Lispro-short-acting insulin) Inject as per sliding scale at bedtime for diabetes mellitus, start date July 5, 2024; Lantus injection (Insulin Glargine- long-acting insulin) at bedtime for diabetes mellitus, start date June 18, 2024; Haloperidol for schizoaffective disorder, start date October 12, 2023; Oxycontin extended release, two times a day for pain, start date November 15, 2023; assess pain level evening shift, start date October 7, 2023; gabapentin for neuropathic pain every 8 hours, start date October 7, 2023 (medication was also not administered July 7 and 14, 2024, at 2:00 PM); accu-checks (blood sugar monitoring) before meals and at bedtime, start date June 26, 2024 (also not monitored July 6th, 2024, nightshift; July 7th, 2024, day shift; and July 14th, 2024, day-evening-night shift).

Review of progress notes July 1st through 17th, 2024, failed to document Resident refusal of medication or treatments.

Review of Resident 40's clinical record revealed diagnoses that included diabetes mellitus and muscle weakness.

Review of Resident 40's MAR during the month of July 2024, revealed on July 14, 2024, the following medications were not shown as administered: Melatonin 5 MG, Omeprazole 20 MG, Glimepiride 4 MG, Magnesium Oxide 4 MG, and Metformin 1000 MG.

Review of Resident 40's progress notes revealed no documentation of a refusal of medications on those dates.

During an interview with the Director of Nursing on July 17, 2024, at 11:30 AM, it was revealed that if medications are refused, it should be documented as such on the Medication Administration Record.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1) Nursing services



 Plan of Correction - To be completed: 08/14/2024

Unable to retroactively document medication administration or refusal for residents 24 and 40.

Director of Nursing/designee will conduct a retroactive two-week baseline audit of the medication administration record of current residents to identify any blanks/missing documentation and complete appropriate follow up needed.

Director of Nursing/designee will educate licensed nursing staff on Ftag 658 and the importance of ensuring medication administration records reflect appropriate administration documentation including administration, refusals, or any other reason for omission of a medication administration and follow up if appropriate.

Director of Nursing/designee will conduct a random sample audit of 5 resident records to ensure no blanks/missing documentation is identified in the medication administration record. These audits will be conducted weekly for 4 weeks and monthly for two months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for review and further recommendations.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident who needs respiratory care is provided care consistent with professional standards of practice for one of three residents receiving oxygen therapy reviewed (Resident 40).

Findings Include:

A review of Resident 40's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - A group of lung diseases that block airflow and make it difficult to breathe) and muscle weakness.

An observation of Resident 40, on July 15, 2024, at approximately 11:00 AM, revealed the use of an oxygen concentrator while in bed in her room.

A review of Resident 40's physician orders revealed none documenting the Resident's need and use of oxygen.

An interview with the Director of Nursing on July 18, 2024, at 9:28 AM, revealed that the facility could not locate an order from the physician for Resident 40's use of oxygen.

28 Pa. Code 211.5 (f) Medical records
28 Pa. Code 211.12 (d) 5) Nursing services


 Plan of Correction - To be completed: 08/14/2024

Unable to retroactively correct physician oxygen order for resident 40.

Director of Nursing/designee will conduct a facility wide audit of residents who require use of oxygen to ensure a physician's order is in place.

Director of Nursing/designee will educate licensed nursing staff on Ftag 695 and the importance of ensuring a physician's order is in place for residents that require oxygen use.

As part of the clinical meeting discussion residents that require use of oxygen will be reviewed to ensure a physician's order is in place for the oxygen use.

Director of Nursing/designee will conduct a random sample audit of 5 residents that require oxygen to ensure a physician's order is in place for the use of oxygen. These audits will be conducted weekly for 4 weeks and monthly for two months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for review and further recommendations.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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.
§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity was reviewed and acted upon for one of five residents reviewed for unnecessary medications (Resident 24).

Findings include:

Review of facility policy, Medication Therapy, revised April 2007, read, in part, the consultant pharmacist shall review each resident's medication regimen monthly, as requested by the staff or practitioner, or when a clinically significant adverse consequence is confirmed or suspected.

Review of Resident 24's clinical record documented diagnoses that included depression (feelings of severe despondency and dejection), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), and schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms such as depression. Symptoms may include delusions, hallucination, depression and manic periods of high energy).

Review of Resident 24's July 2024 physician orders included: escitalopram for depression, start date October 8, 2024; Humalog injection (Insulin Lispro-short-acting insulin) Inject as per sliding scale at bedtime for diabetes mellitus, start date July 5, 2024; Lantus injection (Insulin Glargine- long-acting insulin) at bedtime for diabetes mellitus, start date June 18, 2024; Haloperidol for schizoaffective disorder, start date October 12, 2023; Oxycontin extended release, two times a day for pain, start date November 15, 2023; assess pain level eve shift, start date October 7, 2023.

Further review of Resident 24's clinical record failed to reveal documentation that monthly pharmacy medication reviews were completed.

During an interview with Employee 4 (Registered Nurse) on July 17, 2024, at 3:00 PM, it was revealed that the monthly pharmacy medication reviews are not documented in the "hard chart"/medical record.

During an interview with the Director of Nursing on July 17, 2024, at 3:20 PM, it was revealed that the monthly pharmacy reviews are completed monthly off-site, and that the pharmacy should send a list of residents reviewed and any recommendations from the Pharmacist. It was also revealed that she is having difficulty locating documentation to verify the monthly pharmacy reviews were completed.

28 Pa. Code 211.10(a)(c) Resident care policies
28 Pa. Code 211.12(d)(1)(3) Nursing services


 Plan of Correction - To be completed: 08/14/2024

Most recent pharmacy recommendations for resident 24 have been reviewed by physician with documented action taken based on the pharmacy recommendations and record review completed for medication regimen review by pharmacy consultant, documentation in the clinical record of reasonable if declination of any recommendations and physician acknowledgement signature of receipt of recommendations.

The Director of Nursing/designee will complete a facility wide audit of current residents to ensure most recent pharmacy recommendations have been addressed timely, documentation of follow up action in response to pharmacy recommendations, documentation of rationale for declination of recommendations and physician acknowledgement signature of receipt of recommendations.

The Nursing Home Administrator/designee will educate the Director of Nursing on F756 and the importance of ensuring medication reviews are completed by consulting pharmacist, timely response to pharmacy recommendations, documentation of rationale when recommendations are declined and physician acknowledgement signature of receipt of recommendations.

As part of the distribution group the Nursing Home Administrator will be included to allow the Nursing Home Administrator to provide oversight of the pharmacy recommendation follow up process.

Director of Nursing/designee will conduct a random sample audit of 5 residents to ensure medication reviews have been completed by consulting pharmacist, timely response to pharmacy recommendations, documentation for rationale of any declined recommendations and physician acknowledgement signature of recommendations. These audits will be conducted weekly for four weeks and monthly for two months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for review and recommendations.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:

Based on observations, staff interviews, and policy review, it was determined that the facility failed to ensure adherence to appropriate labeling of medication for one of two medication carts (front hall cart).

Findings include:

Review of facility policy, titled "Administering Medications", last reviewed June 2024, revealed that the expiration/beyond use date on the medication label is checked prior to administering. When opening the multi-dose medication, the date opened is recorded on the medication container. The policy also stated, "Insulin pens are clearly labeled with the resident's name, or other identifying information prior to use."

Observation during the front hall medication cart review on July 16, 2024, at 1:35 PM, revealed one Novolog insulin pen (aka insulin aspart-a fast acting insulin) in Resident 1's medication compartment opened, without a resident identifier, or the date it was removed from the refrigerator. This insulin is to remain in the refrigerator until opened for use, and then expires in 28 days after opening.

During an interview with Employee 10 (Licensed Practical Nurse) on July 16, 2024, at 1:45 PM, Employee 10 confirmed the Novolog insulin pen should have been labeled with the Resident 1's name and dated when removed from the refrigerator and placed into use. Employee 10 also confirmed that the Novolog insulin expires 28 days after opening. Employee 10 discarded the Novolog insulin.

Observation during medication cart review on July 16, 2024, at 1:35 PM, revealed two Lantus insulin (aka Insulin glargine- a long acting man-made insulin) unopened in Resident 1's medication compartment of the medication cart, without a resident identifier, or the date it was removed from the refrigerator and placed in the medication cart. The Lantus insulin both had stickers on to refrigerate, indicating the medication is to be refrigerated until removed to the medication cart, and expires 28 days after removed from refrigeration.

During an interview with the Director of Nursing (DON) on July 17, 2024, the DON agreed that policy should be followed and both the Lantus and Novolog insulins should have been labeled with the Resident's name and the date they were removed from the refrigerator.

28 Pa. Code 211.12(d)(1)(2)(5)Nursing services



 Plan of Correction - To be completed: 08/14/2024

Expired and/or improperly labeled medications were discarded. No harm occurred as a result of this alleged deficient practice.

Director of Nursing/designee will conduct a facility wide audit of medication carts to ensure no medications are expired or undated including insulin medications.

Director of Nursing/designee will educate licensed nursing staff on Ftag 761 and the importance of labeling, dating medications and checking expiration dates as part of their administration process including insulin medications.

Consultant Pharmacist will provide additional checks to medication carts as part of their routine visits at least quarterly or more often as needed.

The Director of Nursing/designee will audit one medication cart for expired and unlabeled medications. These audits will be conducted weekly for four weeks and monthly for two months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for review and recommendations.

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee: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.
§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§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:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.
Observations:

Based on state regulations, review of facility documents, and staff interview, it was determined that the facility failed to ensure that the Medical Director and Infection Preventionist (IP) was in attendance at least quarterly at the Quality Assurance Process Improvement (QAPI) Committee meetings, and failed to provide sign-in records for QAPI Committee meetings for one of four quarters (first quarter).

Findings include:

Review of the CFR (Code of Federal Regulations) revealed:
Quality assessment and assurance.
Quality assessment and assurance.
A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
The director of nursing services, The Medical Director or his/her designee, At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member, or other individual in a leadership role, The Infection Preventionist, and Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

Review of QAPI Committee meeting sign-in sheets were provided for the period of November 2023 through June 2024, there was no August 2023 sign in sheet provided.

Review of QAPI Committee Meeting sign-in sheets included the following dates: November 8, 2023; February 14, 2024; and May 31, 2024. The Medical Director was not in attendance for the November 8, 2023, meeting. There was no credentialed IP and, therefore, no IP in attendance at any of the meetings provided.

During an interview with the Nursing Home Administrator (NHA) on July 18, 2024, at 10:30 AM, the NHA confirmed that the facility failed to make certain that the Medical Director was in attendance at least quarterly at the QAPI Committee meetings for one of the four meetings provided, and failed to provide a sign in sheet for QAPI Committee meetings for one of four quarters (first quarter). The NHA confirmed there was no IP at the meetings.

28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.18(e)(2)(3) Management


 Plan of Correction - To be completed: 08/14/2024

Facility's list of QAPI attendees and revised schedule of quarterly QAPI meetings have been updated to include invitation and participation of the facility's Medical Director an Infection Preventionist.

Nursing Home Administrator will educate members of the QAA committee on Ftag F868 and the importance of ensuring all required participants attend the QAA Committee meeting including but not limited to the Medical Director and the Infection Preventionist.

Administrator/designee will continue to monitor attendance of all quarterly QAPI meetings and review attendance sheet to ensure participation of the required members.

§ 201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on staff interviews and review of the facility's Infection Control Committee attendance records, the facility failed to ensure that one of nine required multidisciplinary members were present at the Infection Control meetings, (Infection Control Preventionist), and failed to ensure all infections meeting criteria were reported to
Pennsylvania Patient Safety Authority Reporting System (PA-PSRS) and to the resident/resident representative for nine of 12 months (October 2023, November 2023, December 2023, January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, and up to July 18, 2024).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L.154, No. 13), known as the Medical Care Availability and Reduction of Error (Mcare) Act, Chapter 4, Section 403(1) Infection Control plan states, "A health care facility... shall develop and implement an internal infection control plan that shall include...a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members include Medical Staff, Administration, Nursing Staff, Patient Safety Officer, Physical Plant Personnel, a community member, laboratory personnel, pharmacy staff, and infection control team members.

Review of the facility's Infection Control Committee attendee signature pages for the November 8, 2023; February 14, 2024; May 31, 2024; and June 28, 2024, meetings, revealed no Infection Control Preventionist (IP) was present at the meetings.

During an interview with the Director of Nursing (DON) on July 18, 2024, at 11:20 AM, the DON confirmed that all nine interdisciplinary members should attend the scheduled infection control meetings.

Review of Act 52, Section 1303.404(a) Health Care Facility Reporting stated, "infections that meet the criteria in the PA-PSRS manual must be reported to PA-PSRS. Section 1303.405(a) Health Care Facility Reports to Authority, requires the facility to provide written notification to the resident/resident representative when any health care-associated infection is acquired."

During an interview with the DON on July 18, 2024, at 11:20 AM, the DON confirmed the facility failed to track infection control data, and failed report any health care acquired infections to PA-PSRS or to the residents/resident representative since September 2023. The DON also informed this surveyor that the facility is currently are training a Registered Nurse for the IP position while she obtains certification for the position.


 Plan of Correction - To be completed: 08/14/2024

The facility is unable to retroactively provide attendance for the missing Infection Control Meeting member or report to Pennsylvania Patient Safety Authority Reporting System (PA -PSRS) for the identified missing months due to time lapse.

The Infection Preventionist has updated the meeting dates and times of the Infection Control meetings and included the participation of the required multidisciplinary team members including but not limited to Medical staff, Administration, Nursing Staff, Patient Safety Officer, Physical Plant Personnel, a community member, laboratory personnel, pharmacy staff, and infection control team member. The Infection Preventionist will report the infections for the month of July 2024 to the Patient Safety Authority (PA-PSRS) website.

The Director of Nursing/designee will educate the facility Infection Preventionist on P1020 and the importance of ensuring all required members of the multidisciplinary team attend and participate in the Infection Control meetings and ensuring monthly reporting of infections to the Patient Safety Authority (PA-PSRS) website.

The Infection Preventionist will audit reporting to the Patient Safety Authority (PA-PSRS) website monthly and the attendance of the required members of the multidisciplinary team on a quarterly basis. Results of these audits will be reviewed through the Quality Assurance Performance Improvement Committee for additional recommendations as necessary.

§ 201.22(a) LICENSURE Prevention, control and surveillance of tuber:State only Deficiency.
(a) The facility shall have a written TB infection control plan with established protocols which address risk assessment and management, screening and surveillance methods, identification, evaluation, and treatment of residents and employees who have a possible TB infection or active TB.

Observations:

Based on review of personnel records, review of facility policy, and interviews with staff, it was determined that the facility failed to complete 2-step intradermal tuberculin skin testing for three of five employees reviewed (Employees 5, 6, and 7).

Findings include:

Facility policy, Employee Screening for Tuberculosis, revised July 2023, read, in part, all employees are screened for latent tuberculosis, and active tuberculosis disease, using tuberculin skin test, or interferon gamma release assay and symptom screening prior to beginning employment. Screening includes a baseline test for latent tuberculosis using the skin test or IGRA. If the baseline test is negative and there is not risk factors, no additional testing is completed. If the baseline test ins positive and there is no risk factors, a second test is conducted. If the Mantoux tuberculin skin test is used for the baseline test of healthcare personnel, use the two-step testing.

Review of Employee files for Employees 5, 6, and 7 failed to reveal that a 2-step Mantoux tuberculin skin test was completed prior to beginning of employment.

During an interview with the Nursing Home Administrator on July 17, 2024, at 11:45 AM, it was revealed that, per facility policy, new hires complete Tuberculosis Baseline Questionnaire and, if there are no risk factors, a step-1 Mantoux Tuberculin skin test is completed, and if the step-1 test is negative, a step-2 test isn't completed. A step-2 test would be completed if the staff member had a positive step-1 test or risk factors listed on the baseline questionnaire.


 Plan of Correction - To be completed: 08/14/2024

Unable to retroactively perform a two-step PPD intradermal tuberculin test prior to hire for employees 5, 6, and 7 due to time lapse of pre-hire.

The facility has updated the written Tuberculosis Infection Control plan policy to include a two-step intradermal tuberculin test prior to employee start date as part of the hiring process or use another acceptable form of tuberculosis test recognized and accepted by the CDC like a chest x-ray or QuantiFERON Gold test.

The Infection Preventionist/designee will complete a facility wide audit of current employees to identify employees that may not have received a two-step intradermal tuberculin test or other acceptable and recognized tuberculosis test like a chest x-ray or QuantiFERON Gold test.

The Infection Preventionist/designee will educate the facility hiring manager on P1690 and the importance of ensuring employees receive a two-step PPD intradermal tuberculin test or other acceptable and recognized tuberculosis test like a chest x-ray or QuantiFERON Gold test.

The Infection Preventionist/designee will conduct a random sample audit of 5 new employees to ensure they have received a two-step intradermal tuberculin test or other acceptable and recognized tuberculosis test like a chest x-ray or QuantiFERON Gold test. Results of these audits will be reviewed through the Quality Assurance Performance Improvement Committee for additional recommendations as necessary.


§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on staffing documents and staff interview, it was determined that the facility failed to ensure a required minimum of one Nurse Aide (NA) per 11 residents on evening shift and one NA per 15 residents on night shift, effective July 1, 2024, for six of seven days reviewed (July 11 - 16, 2024); and failed to ensure a required minimum of one NA per 12 residents on evening shift (June 23 and 28, 2024) and one NA per 20 residents on night shift (May 28, 2024; June 24, 2024).

Findings include:

Review of facility staffing ratio and resident census information for July 11 through 17, 2024, revealed the following NA ratios, which did not meet the minimum NA ratio required for the resident census on the following shifts:

7/11/2024 Night shift - 42 residents and 1.11 NAs, which did not meet the required ratio of 2.80 NAs.
7/12/2024 Night shift - 41 residents and 2.04 NAs, which did not meet the required ratio of 2.73 NAs.
7/13/2024 Night shift - 40 residents and 1.12 NAs, which did not meet the required ratio of 2.67 NAs.
7/14/2024 Evening shift - 39 residents and 3.24 NAs, which did not meet the required ratio of 3.55 NAs.
7/14/2024 Night shift - 39 residents and 1.33 NAs, which did not meet the required ratio of 2.60 NAs.
7/15/2024 Night shift - 39 residents and 2.09 NAs, which did not meet the required ratio of 2.60 NAs.
7/16/2024 Night shift - 39 residents and 2.26 NAs, which did not meet the required ratio of 2.60 NAs.

Review of facility staffing ratio and resident census information for June 23 through 29, 2024, revealed the following NA ratios, which did not meet the minimum NA ratio required for the resident census on the following shifts:

6/23/2024 Evening shift - 42 residents and 3.12 NAs, which did not meet the required ratio of 3.50 NAs.
6/24/2024 Night shift - 42 residents and 1.10 NAs, which did not meet the required ratio of 2.10 NAs.
6/28/2024 Evening shift - 43 residents and 1.19 NAs, which did not meet the required ratio of 1.72 NAs.

Review of facility staffing ratio and resident census information for May 26, 2024, through June 1, 2024, revealed the following NA ratios, which did not meet the minimum NA ratio required for the resident census on the following shifts:

5/28/2024 Night shift - 40 residents and 1.20 NAs, which did not meet the required ratio of 2.00 NAs.

During an interview with the Nursing Home Administrator and Director of Nursing on July 17, 2024, at 11:00 AM, both were aware that NA ratios are not meeting the staffing requirements for 10 of 21 days reviewed.


 Plan of Correction - To be completed: 08/14/2024

Nursing Home Administrator will audit nursing staffing schedules for the next two weeks to ensure schedules reflect at a minimum 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Nursing Home Administrator/designee will educate Director of Nursing and facility Nursing Scheduler on P5520 and the importance of ensuring compliance with nurse aide ratios as mandated by state laws regarding mandated minimum staffing requirements.

Nursing Home Administrator will have a daily staffing meeting with Director of Nursing and facility Nursing Scheduler to review daily staffing schedules to ensure compliance with staffing regulations, discuss potential barriers to meeting required staffing ratios and identify strategies to meet staffing ratios including but not limited to recruitment efforts, bonus structure, use of agency and overtime hours.

Nursing Home Administrator will audit daily nursing staffing ratios to ensure nurse aide ratios are in compliance with mandated state laws regarding minimum staffing ratios. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for review and recommendations.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(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 staffing document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Licensed Practical Nurse (LPN) per 25 residents on day shift and one LPN per 30 residents on evening shift, effective July 1, 2024, for one of seven days (July 14, 2024); and failed to have one LPN per 25 residents on day shift for two of 21 days reviewed (June 29, 2024 and May 26, 2024), and one LPN per 30 resident on evening shift for two of 21 days reviewed (June 23, 2024 and May 26, 2024).

Findings include:

Review of three weeks of facility staffing ratio and resident census information (July 11 through 17, 2024; June 23 through 29, 2024; and May 26, 2024, through June 1, 2024) revealed the following LPN ratios, which did not meet the minimum LPN ratio required for the resident census on the following shifts:

7/14/2024 Day shift - 39 residents and 1.09 LPNs, which did not meet the required ratio of 1.56 LPNs.
7/14/2024 Evening shift - 39 residents and 1.09 LPNs, which did not meet the required ratio of 1.30 LPNs.
6/23/2024 Evening shift - 42 residents and 3.12 LPNs, which did not meet the required ratio of 1.40 LPNs. 6/29/2024 Day shift - 43 residents and 1.19 LPNs, which did not meet the required ratio of 1.72 LPNs.
5/26/2024 Day shift - 39 residents and 1.29 LPNs, which did not meet the required ratio of 1.50 LPNs.
6/29/2024 Day shift - 39 residents and 1.06 LPNs, which did not meet the required ratio of 1.30 LPNs.

During an interview with the Nursing Home Administrator and Director of Nursing on July 17, 2024, at 11:00 AM, both were aware that LPN ratios are not meeting the staffing requirements for 10 of 21 days reviewed.


 Plan of Correction - To be completed: 08/14/2024

Nursing Home Administrator will audit nursing staffing ratios for next two weeks to ensure that at minimum schedules reflect 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Nursing Home Administrator/designee will educate Director of Nursing and facility Nursing Scheuler on P5530 and the importance of meeting LPN ratios as established by state staffing mandate.

Nursing Home Administrator will have a daily staffing meeting with Director of Nursing and facility Nursing Scheduler to review daily staffing schedules to ensure compliance with staffing regulations, discuss potential barriers to meeting required staffing ratios and identify strategies to meet staffing ratios including but not limited to recruitment efforts, bonus structure, use of agency and overtime hours.

Nursing Home Administrator will audit daily nursing staffing ratios to ensure LPN ratios are in compliance with mandated state laws regarding minimum staffing ratios. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for review and recommendations.

§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, 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 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of staffing documents and staff interview, it was determined that the facility failed to ensure the total number of nursing care hours provided in each 24 hour period met the required minimum of 3.20 hours of direct care per resident, effective July 1, 2024, for one of 21 days reviewed (July 14, 2024).

Findings include:

Review of three weeks of facility staffing hours that included May 26, 2024 through June 1, 2024; June 23 through 29, 2024; and July 11 through 17, 2024, revealed that the facility provided only 3.05 hours of direct care per resident on July 14, 2024.

During an interview with the Nursing Home Administrator (NHA) on July 18, 2024, at 11:00 AM, the NHA was aware of the 21 days of staffing under review, and aware that the facility did not meet the required staffing hours of direct care for July 14, 2024.


 Plan of Correction - To be completed: 08/14/2024

Nursing Home Administrator will review nursing staffing ratios for the next two weeks to ensure the total number of hours of general nursing care provided in each 24-hour period l, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Nursing Home Administrator/designee will educate Director of Nursing and facility Nursing Scheduler on P5640 and the importance of maintaining compliance with requirements of general nursing care hours in each 24-hour period of a minimum of 3.2 hours of direct care for each resident.

Nursing Home Administrator will have a daily staffing meeting with Director of Nursing and facility Nursing Scheduler to review daily staffing schedules to ensure compliance with staffing regulations and required minimum direct care hours for each resident, discuss potential barriers to meeting required staffing ratios and identify strategies to meet staffing ratios including but not limited to recruitment efforts, bonus structure, use of agency and overtime hours.

Nursing Home Administrator/designee will audit daily staffing ratios and direct nursing care hours for each resident in a 24-hour period. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for review and recommendations.


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