Pennsylvania Department of Health
MILLCREEK MANOR
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MILLCREEK MANOR
Inspection Results For:

There are  101 surveys for this facility. Please select a date to view the survey results.

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MILLCREEK MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance Survey, and an Abbreviated Complaint Survey completed on February 23, 2024, it was determined that Millcreek Manor 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:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:


Based on review of facility policy, clinical and hospital records, and resident and staff interviews, it was determined that the facility failed to implement sufficient safety precautions to prevent a resident with a history of suicide attempt by overdose, from appropriating a significant number of prescription medications that resulted in an overdose of the prescription medications that were provided during medication administration by the facility for one (Resident R234) of three residents reviewed with a history of suicide attempts, and resulted in an Immediate Jeopardy situation.

Findings include:

Review of a facility policy entitled "Medication Administration" dated 10/30/23, indicated that staff will remain at bedside with the resident until all medications are taken.

Resident R234's clinical record revealed an admission date of 10/09/23, with diagnoses that included major depressive disorder, anxiety, long-term pain, spinal stenosis (inflammation of the vertebrae causing compression of the spinal cord) of the neck, and epilepsy.

Resident R234's clinical record lacked evidence of a care plan addressing safety interventions to prevent suicide attempts and to include safety measures to prevent an overdose of medications.

Review of Resident R234's physician orders revealed an order dated 10/11/23, to administer Tizanidine HCL (medication to reduce muscle spasms often used with spinal cord injuries) four milligram tablet four times per day for pain.

Further review of Resident R234's clinical record revealed:

A physician's progress note dated 10/10/23, that identified that Resident R234 had attempted to overdose on medication in August 2023.
A departmental progress note dated 10/10/23, revealed that the results of Resident R234's Basic Interview of Mental Status (BIMS)- scored 15 (intact cognition).
A physician's order dated 10/11/23, to administer Tizanidine for pain four times per day.
A practitioner progress note dated 10/18/23, revealed facility knowledge of two previous attempted over-doses.
A practitioner progress note dated 10/25/23, revealed Resident R234 expressed increased pain and feeling "miserable" since admission.
A departmental progress note dated 12/31/23, revealed Resident R234 reported to staff that he/she was "extremely depressed."
A Social Services progress note dated 1/06/24, indicated that psychological/psychiatric services were not indicated.
A practitioner progress note dated 1/11/24, indicated that Resident R234 had not seen psychiatry services since 10/26/23.
A Social Services progress note dated 1/15/24, indicated that Resident R234's BIMS remained a 15.
A departmental progress note dated 1/30/24, indicated staff found a box of approximately 100 Tizanidine tablets in a box in Resident R234's room.

Review of hospital records revealed:

An Intensive Care Unit (ICU) Inpatient Record and Progress Note dated 1/30/24, listed Resident R234's admitting diagnosis as "Tizanidine overdose," and that the hospital contacted the Poison Control Center for recommended management.

Review of a History and Physical Admission Exam dated 1/30/24, revealed that Resident R234 was found to be completely unresponsive, and that facility staff had found a stash of his/her muscle relaxers (Tizanidine). Resident R234 was treated in the Emergency Department and admitted to ICU for evaluation and management of Tizanidine overdose.
A Behavioral Health Evaluation dated 2/01/24, revealed that Resident R234 had been "hoarding" Tizanidine while at the Senior Living Center; then took a large amount of the medication with the intention of killing herself; that he/she planned out how to save his/her medication; took them with the intention of killing herself; had a prior psychiatric history of three suicide attempts (21 years ago- overdose of Aspirin, 8/23/23-overdose of Oxycodone, 1/30/24-overdose of Tizanidine).

During an interview on 2/20/24, at 3:03 p.m. resident stated:

"He/she was able to hoard his/her muscle relaxer (Tizanidine) over time and get enough to attempt to commit suicide on 1/30/24; he/she stated that is wasn't hard, as many nurse's didn't stay in the room while he/she took her pills and he/she easily slipped them into the sheets, and there were certain nurses who stayed in the room so he/she came up with a way to have his/her pills delivered in separate cups. While they weren't paying attention he/she was able to stack an empty cup into the cup with his/her Tizanidine to hide it, once he/she stacked all of the cups, the nurse's would throw the whole stack in the trash, once the nurse left the room, then he/she would retrieve the medication out of the trash and put it in his/her drawer. Resident R234 also stated that he/she kept asking to see a VA (Veteran's Administration) doctor and a counselor. When he/she was admitted, the Social Worker told him/her to call anytime, and that in the afternoon on 1/30/24, he/she left a message and didn't hear back, later that day he/she took the pills."
Resident R234 disclosed that if the nurse's had been more diligent with watching him/her take his/her meds, he/she would not have been able to attempt suicide. The facility knew on admission that he/she was a risk for this and did nothing.

During an interview on 2/20/24, at 4:30 p.m. the Director of Nursing (DON) confirmed that staff have not completed competencies on medication administration pass since last summer.

During an interview on 2/20/24, at 4:57 p.m. the current Nursing Home Administrator (NHA) confirmed that there were no staff competencies for medication administration.

The facility failed to implement sufficient safety measures to prevent appropriating prescription medications, putting three residents with a history of suicide attempts at risk and causing an Immediate Jeopardy situation.

The NHA and DON were notified of the Immediate Jeopardy (IJ) situation on February 20, 2024, at 5:35 p.m. An Immediate Plan of Correction was requested and the IJ Template was provided.

The Immediate Action Plan was provided by the NHA and DON on February 20, 2024, at 7:08 p.m. which was accepted at 7:26 p.m.

The plan included:

1. Resident R234's care plan was updated to include; crushing medications, observe resident taking medications and ensuring it is swallowed; every 15 minutes checks; psych services as needed; diversion activities; involve family; behavioral tracking and addressing feelings of loss/suicidal ideations; involve physician, psych services and family with indications of suicidal ideations; and contact and facilitate mental health inpatient stay as needed.
2. All other residents with suicidal ideations will have psych services in place.
3. Staff will observe and ensure medication are taken and swallowed before exiting the room.
4. Facility will offer Mental Health inpatient services.
5. Preventative and safety precautions will be implemented as needed.
6. Each resident's needs will be addressed individually specific to their psychological needs.
7. Care plans will be updated to reflect the present plan of care.
8. Effective immediately, all nurses will be trained on proper medication administration.
9. Training will be completed by 2/24/24.
10. Training will be completed before each nurse works on the units.
11. The above plan will be reviewed at the Quality Assurance Performance Improvement Meeting.

Review of facility documentation 100% of nurses working on the units between 2/20/24, at 7:26 p.m. and 2/21/24, at 11:00 a.m. received the medication administration training.

Interviews on 2/21/24, between 8:30 a.m. and 10:40 a.m. revealed six licensed nursing staff confirmed that they received medication administration training prior to starting their shifts.

On February 21, 2024, at 11:36 a.m. the Immediate Jeopardy was lifted after ensuring the Immediate Action Plan had been implemented.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.10(d) Resident care policies

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







 Plan of Correction - To be completed: 04/01/2024

R234's care plan has been updated to address potential to self harm.
Medications have been changed to liquid form or to be crushed. R 234 has an order for every 15 minute checks. Psychological services are in place. Medication Administration Training was completed with all nurses.

All residents who have a history of suicidal ideations/attempts will have their care plans updated to ensure they are safe. Psychological services will be offered and provided. Closer monitoring will be implemented if needed.

An initial audit will be completed on 100% of residents residing in the facility by the ADON/designee to ensure safety measures are in place and are reflected in their Care Plans. This includes but is not limited to psychological services, closer monitoring; every 15 minute checks or one on one staffing, medication monitoring, keeping room free of hazards. The Nursing Home Administrator will ensure completion.

The nurses and Interdisciplinary Team will be trained by the Assistant Director of Nursing/designee on implementing sufficient safety practices.

The Assistant Director of Nursing/designee will audit all new admissions, physician orders to ensure safety measures are in place and care planned accordingly five (5) times a week times two (2) weeks, weekly times two (2) weeks and then monthly times two (2) months. The Nursing Home Administrator/Designee will audit for completion. Safety measures will be updated daily as needed. Care Plans will be updated as needed.

Morning Clinical meeting will occur daily to ensure compliance with implementing appropriate safety measures ongoing.

The Facility has hired an outside provider (Affinity Health Services) to conduct a Directed In-Service Training to be held March 22, 2024.

Results of the audits will be discussed at the Quality Assurance Process Improvement.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp: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)(7) The right to self-administer medications if the interdisciplinary team, as defined by 483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations:


Based on observations, review of facility policy and clinical records and staff interview, it was determined that the facility failed to assess a resident for self-administration of medication for one of 25 residents reviewed (Resident R102).

Findings include:

Review of facility policy entitled "Resident Self-Administration of Medication" dated 10/03/23, indicated that the interdisciplinary team will determine if it is safe for the resident to self-administer drugs before the resident may exercise that right. It also indicated that the interdisciplinary team must determine who will be responsible for the storage and documentation of the administration of drugs and that self-administration of medication will be permitted with the orders of a licensed physician and is monitored by the facility.

Resident R102's clinical record revealed an admission date of 1/19/23, with diagnoses that included schizoaffective disorder (condition with symptoms of schizophrenia and affective disorder at the same time), bipolar disorder, anxiety, and depression.

Observation of medication administration on 2/21/24, at approximately 8:30 a.m. revealed Resident R102 with a bottle of Ipratropium Bromide Nasal spray (medication to treat runny nose caused by colds or allergies) on the bedside tray table. At the time of the observation Resident R102 stated, "I always have my nasal spray on my bedside tray table."

Resident R102's clinical record revealed a physician's order dated 3/01/23, for Ipratropium Bromide Nasal Solution 0.03% two sprays in each nostril as needed for runny nose four times daily.

Resident R102's clinical record lacked a self administration of medication assessment or an order to keep the nasal spray at the bedside. Resident R102's Medication Administration Record (MAR) revealed from the original order date of 3/01/23, to 2/20/204, a period of 11 months and 20 days that Resident R102 was administered the nasal spray on 3/05/23, 3/24/23, 7/22/23, and 7/23/23, a total of four times. An order audit report from the pharmacy for Resident R102 revealed that the nasal spray was ordered on 3/01/23, and re-ordered on 4/10/23, 7/22/23, 9/18/23 and 12/27/23, for a total of 5 bottles that were dispensed from 3/01/23, to 2/20/24.

During an interview on 2/21/2024, at approximately 10:00 a.m. the Nursing Home Administrator confirmed that Resident R102's clinical record lacked a self-administration assessment of medication for Resident R102 for the nasal spray that was at the bedside.

28 Pa. Code 211.5(f)(ii)(iii) Medical records

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










 Plan of Correction - To be completed: 04/01/2024

R102 had a self medication assessment completed. All residents who have a desire to self administer medications will be assessed to determine if they can safely self administer their medications before they do so. If they are deemed appropriate to self administer their medications, their care plan will be updated and their medications will be locked in their rooms where they can access them and document in a medication administration record that they self administered their medications. Nursing will monitor daily to ensure resident is self administering and documenting daily.

All nurses will be trained by the Director of Nursing/designee on completing self administration assessments as needed. The Nursing Home Administrator/designee will monitor to ensure training is completed.

The Director of Nursing/designee will audit new admissions, the 24 hour report listing residents that have a desire to self administer medications and any current residents that self administer medications to ensure they are safe to self administer. The auditing will be completed by both observing residents that self administer and by looking at the assessments to ensure completion (5) times a week times two (2) weeks, weekly times two (2) weeks and then monthly times two (2) months. The Nursing Home Administrator/designee will audit to determine completion.

Audits will be ongoing for all current and new residents for self-administering medications. Results of the audits will be discussed at the Quality Assurance Process Improvement.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:


Based on observations, review of facility policy and clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to medication administration for one of 25 residents reviewed (Resident R102).

Findings include:

Review of facility policy entitled "Resident Self-Administration of Medication" dated 10/03/23, indicated that the interdisciplinary team will determine if it is safe for the resident to self-administer drugs before the resident may exercise that right. It also indicated that the interdisciplinary team must determine who will be responsible for the storage and documentation of the administration of drugs and that self-administration of medication will be permitted with the orders of a licensed physician and is monitored by the facility.

Resident R102's clinical record revealed an admission date of 1/19/23, with diagnoses that included schizoaffective disorder (condition with symptoms of schizophrenia and affective disorder at the same time), bipolar disorder, anxiety, and depression.

Observation of medication administration on 2/21/24, at approximately 8:30 a.m. revealed Resident R102 with a bottle of Ipratropium Bromide Nasal spray (medication to treat runny nose caused by colds or allergies) on the bedside tray table. At the time of the observation Resident R102 stated, " I always have my nasal spray on my bedside tray table."

Resident R102's clinical record revealed a physician's order dated 3/01/23, for Ipratropium Bromide Nasal Solution 0.03% two sprays in each nostril as needed for runny nose four times daily.

Resident R102's clinical record lacked a self administration of medication assessment or an order to keep the nasal spray at the bedside. Resident R102's Medication Administration Record (MAR) revealed from the original order date of 3/01/23, to 2/20/204, a period of 11 months and 20 days that Resident R102 was administered the nasal spray on 3/05/23, 3/24/23, 7/22/23, and 7/23/23, a total of four times. A order audit report from the pharmacy for Resident R102 revealed that the nasal spray was ordered on 3/01/23, and re-ordered on 4/10/23, 7/22/23, 9/18/23 and 12/27/23, for a total of 5 bottles that were dispensed from 3/01/23, to 2/20/24.

During an interview on 2/22/2024, at approximately 8:30 a.m. the Nursing Home Administrator confirmed that Resident R102's clinical record lacked documentation regarding the nasal spray administration.

28 Pa. Code 211.5(f)(ii)(iii) Medical records

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













 Plan of Correction - To be completed: 04/01/2024

R102 has had a self medication assessment completed and it has been determined that she is no longer safe to self administer her medications.

An initial audit of all residents who currently self administer will be completed to ensure they are able to safely administer their medications.

If a resident is deemed appropriate to self administer their medications they will document their medications on a medication administration record. The nurse on the unit will monitor daily to ensure that the resident is documenting.

All nurses will be trained by the Director of Nursing/designee on completing self administration assessments as needed and ensuring residents are documenting their medications. The Nursing Home Administrator/designee will monitor to ensure training is completed.

The Director of Nursing/designee will audit all residents that self administer to ensure they are documenting that they are self administering (5) times a week times two (2) weeks, weekly times two (2) weeks and then monthly times two (2) months.

The Nursing Home Administrator/designee will audit to determine completion.

Pharmacist consultant will review both visually and through proper documentation all residents who self-administer medications to ensure they are safe to self-administer. Pharmacist will report on the monthly pharmacist review results of audit.

Results of the audits will be discussed at the Quality Assurance Process Improvement.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.21 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:


Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for four of 25 residents reviewed (Residents R10, R79, R124, and R117).

Findings include:

A facility policy entitled, "Care Plans" dated 10/30/2023, revealed that "A copy of the care plan will be provided to the resident and/or family/responsible party."

Resident R10's clinical record revealed an admission date of 9/25/2023, with diagnoses that included hypertension (high blood-pressure), hyperlipidemia (high cholesterol), and a femur fracture.

R10's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R10 and/or his/her representative.


Resident R79's clinical record revealed an admission date of 1/5/2024, with diagnoses that included hypertension, muscle weakness, and a femur fracture.

R79's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R79 and/or his/her representative.


Resident R124's clinical record revealed an admission date of 12/15/2023, with diagnoses that included hypertension anxiety, and Parkinson's disease (a progressive disorder that affects the nervous system and can cause tremors, stiffness, and poor balance).

R124's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R124 and/or his/her representative.


Resident R117's clinical record revealed an admission date of 10/11/2023, with diagnoses that included diabetes (condition of improper blood sugar control), hypertension (high blood pressure), and osteomyelitis of vertebra (infection in the bone of the vertebra).

R117's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R117 and/or his/her representative.

During an interview on 2/22/2024, at 3:45 p.m. the Director of Nursing confirmed that the clinical records for the residents listed above lacked evidence that a written summary of the baseline care plan and order summary was provided the resident and/or his/her representative upon admission to the facility.

28 Pa. Code 201.14(a) Responsibility of licensee



 Plan of Correction - To be completed: 04/01/2024

Resident R10, R79, R117 and R124 had a baseline care plan and list their list of prescribed medications given to them.
All residents admitted to the facility in the last thirty (30) days will be audited to ensure their baseline care plan and list of prescribed medications were given to them. If they were not provided, they will be provided and documented. The Nursing Home Administrator/Designee will audit for completion.

The nurses and Interdisciplinary Team will be trained by the Director of Nursing/designee on completing a baseline care plan on all new admissions within 48 hours of admission. They will further be trained on providing the care plan and a list of prescribed medications to the resident/family/POA within 48 hours of admission.

The Director of Nursing/designee will audit all new admissions and to ensure that the baseline care plan has been developed within 48 hours and the resident/family/POA has been provided a copy of the care plan as well as a list of prescribed medications five (5) times a week times two (2) weeks, weekly times two (2) weeks and then monthly times two (2) months. The Nursing Home Administrator/Designee will audit for completion.

Quality audit will be developed to audit all new admissions to ensure baseline care plan and medication list has been given to the resident/family ongoing. Corrections will be completed as needed.

Results of the audits will be discussed at the Quality Assurance Process Improvement.

483.20(b)(2)(ii) REQUIREMENT Comprehensive Assessment After Signifcant Chg: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.
483.20(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)
Observations:


Based on review of the Minimum Data Set (MDS-periodic assessment of resident care needs) User's Manual, clinical record, and staff interview, it was determined that the facility failed to complete a comprehensive assessment after a significant change in condition for one of five residents receiving hospice services (Resident R89).

Findings include:

Review of the MDS User's Manual revealed that a significant change in status assessment is required to be performed when a terminally ill resident enrolls in a hospice program and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14-days from effective date of the hospice election.

Resident R89's clinical record revealed an admission date of 9/23/23, with diagnoses that included Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), muscle wasting, neurogenic bowel (the loss of normal bowel function), and cognitive communication deficit (difficulty with thinking and how someone uses language). The clinical record revealed a physician's order dated 10/26/23, to admit Resident R89 to Hospice services.

Review of Resident 89's MDS's lacked evidence that a significant change MDS with an ARD completed within 14-days from when Resident R897 was admitted to hospice care was completed.

During an interview on 2/22/24, at 1:00 p.m. the Licensed Practical Nurse Assessment Coordinator Employee E2 confirmed that the significant change MDS was not completed within 14-days of Resident R89 entering Hospice services.

28 Pa. Code 201.14(a) Responsibility of licensee



 Plan of Correction - To be completed: 04/01/2024

Resident R89 MDS was corrected and resubmitted.

The facility will complete a comprehensive assessment with any significant change within 14 days after the facility determines that there has been a significant change in a resident's physical or mental condition.
An audit will be completed by the Registered Nurse Assessment Coordinator to ensure comprehensive assessments with significant changes have been completed for the last three (3) months.

Corrections will be completed as needed.
The Registered Nurse Assessment Coordinator and the Licensed Practical Nurse Assessment Coordinator will be trained by Director of Nursing/designee on completing comprehensive assessments per the federal and state mandates. The Nursing Home Administrator will monitor to ensure completion.

The Nursing Home Administrator/designee will audit all MDS's completed by the Registered Nurse Assessment Coordinator and the Licensed Practical Nurse Assessment Coordinator to ensure that assessments are completely correctly five (5) times a week times two (2) weeks, weekly times two (2) weeks and then monthly times two (2) months.

Twenty-five percent of MDS's completed on a monthly basis will be audited for accuracy and completion. Results of the audits will be reviewed at the Quality Assurance Meeting.

483.20(g) REQUIREMENT Accuracy of Assessments: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.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on review of clinical records and facility documentation, and staff interview, it was determined that the facility failed to complete the Minimum Data Set (MDS-periodic assessment of resident care needs) to accurately reflect the resident's status at the time of the assessment for one of 25 residents reviewed (Resident R67).

Findings include:

Resident R67's admission record revealed an admission date of 1/30/2023, with diagnoses that included dementia, depression, and pain.

Resident R67's clinical record revealed that Hospice (end-life services) was ordered on 1/30/2023 and has continued throughout R67's stay at the facility.

The Annual MDS dated 11/06/2023, Section O110. Special Treatments, Procedures, and Programs category K1. Hospice was marked "No" indicating Resident R67 was not receiving Hospice services.

During an interview on 2/22/2024, at 12:58 p.m. Licensed Nurse Assessment Coordinator Employee E2 confirmed that Section O110. Special Treatments, Procedures, and Programs category K1. Hospice for the Quarterly MDS dated 11/06/23, was incorrectly coded for Resident R67 regarding Hospice care services.

28 Pa. Code 201.14(a) Responsibility of licensee






 Plan of Correction - To be completed: 04/01/2024

R67's MDS was corrected to reflect the resident's status at the time of the assessment.

An audit will be completed by the Registered Nurse Assessment Coordinator to ensure assessments completed in the last 30 days reflect the status of the residents at the time of the assessment have been completed for the last three (3) months. Corrections will be completed as needed.

The Registered Nurse Assessment Coordinator and the Licensed Practical Nurse Assessment Coordinator will be trained by Director of Nursing/designee on completing assessments to reflect the residents status at the time of the assessment per the federal and state mandates. The Nursing Home Administrator will monitor to ensure completion.

The Nursing Home Administrator/designee will audit the Registered Nurse Assessment Coordinator and the Licensed Practical Nurse Assessment Coordinator will audit all hospice residents to ensure proper coding and completion five (5) times a week times two (2) weeks, weekly times two (2) weeks and then monthly times two (2) months.

Twenty-five percent of MDS's completed on hospice residents will be monthly for accuracy and completion. Results of the audits will be reviewed at the Quality Assurance Meeting

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 review of facility policy and clinical records, it was determined that the facility failed to implement a person-centered care plan that included safety precautions for a resident with a history of suicide attempt by overdose, for one of 25 residents reviewed (Resident R234).

Findings include:

A facility policy entitled, "Care Plans (Plans of Service)" dated 10/30/23, indicated that the facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental/psychosocial needs within 10 days of admission.

Resident R234's clinical record revealed an admission date of 10/09/23, with diagnoses that included major depressive disorder, anxiety, long-term pain, spinal stenosis (inflammation of the vertebrae causing compression of the spinal cord) of the neck, and epilepsy.

Resident R234's clinical record revealed a care plan related to major depressive disorder which lacked interventions to ensure resident safety related to previous suicide attempts with an overdose.

Further review of Resident R234's clinical record revealed:

A physician's progress note dated 10/10/23, that identified that Resident R234 had attempted to overdose on medication in August 2023.
A departmental progress note dated 10/10/23, revealed that the results of Resident R234's Basic Interview of Mental Status (BIMS)- scored 15 (intact cognition).
A practitioner progress note dated 10/18/23, revealed facility knowledge of two previous attempted over-doses.
A practitioner progress note dated 10/25/23, revealed Resident R234 expressed increased pain and feeling "miserable" since admission.
A departmental progress note dated 12/31/23, revealed Resident R234 reported to staff that he/she was "extremely depressed."
A practitioner progress note dated 1/11/24, indicated that Resident R234 had not seen psychiatry services since 10/26/23.

The facility was aware of Resident R234's history of suicide attempt previously and did not develop a comprehensive person-centered care plan with adequate safety precautions to address that concern.

Refer to F689

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



 Plan of Correction - To be completed: 04/01/2024

A Comprehensive Care Plan was developed and provided to R234.

A Comprehensive Care plan will be developed and provided to all residents within 14 days of admission.

An initial audit of all residents will be completed to ensure they have a comprehensive care plan in place. Care plans will be completed as needed.
The nurses and Interdisciplinary Team will be trained by the Director of Nursing/designee on completing comprehensive care plans on all new admissions within 14 days of admission.

The Director of Nursing/designee will audit all new admissions, physician orders and progress notes to ensure they have a comprehensive care plan in place within 14 days of admission five (5) times a week times two (2) weeks, weekly times two (2) weeks and then monthly times two (2) months. The Nursing Home Administrator/Designee will audit for completion. Care Plans will be updated daily as needed.

Quality audit will be developed to ensure comprehensive care plans are created within 14 days of admission, audits will be ongoing and corrections will be made as needed.

Results of the audits will be discussed at the Quality Assurance Process Improvement.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:


Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for one of five residents reviewed (Resident R61).

Findings include:

A facility policy entitled "PRN Psychotropic Medication Use," dated 10/30/23, indicated that "all PRN non-antipsychotic psychotropic medications will be limited to an initial duration of 14 days or less," and "Use may be extended beyond 14 days upon provider ... documentation of rationale and expected duration."

Review of Resident R61's clinical record revealed an admission date of 4/28/21, with diagnoses that included Generalized Anxiety Disorder (a disorder that causes a person to feel nervous), Hypertension (high blood pressure), and Chronic Obstructive Pulmonary Disease (a disease that causes obstructed airflow from the lungs).

Review of Resident R61's medication orders revealed a physician order dated 2/8/24, to administer Vistaril (anti-anxiety medication) 25 milligrams (mg) every six hours PRN for anxiety. The medication lacked the required stop date within 14 days or a clinical rational for continuing beyond 14 days.

During an interview on 2/23/2024, at 9:23 a.m. the Assistant Director of Nursing confirmed that Resident R61's Vistaril order lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days.

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







 Plan of Correction - To be completed: 04/01/2024

R 61 is now on hospice and receiving prn psychotropic. Justification for the medication is end of life services.

All prn psychotropic medications were audited to ensure there is a stop date in place or documentation with rational to continue the medication. Corrections were made as needed.

The nurses will be trained by the Director of Nursing/designee on ensuring there is a stop date in place for all prn psychotropic medications unless there is documentation with rational to continue the medication.

The Director of Nursing/designee will audit all new orders and progress notes at clinical morning meeting to ensure there are stop dates for all residents on prn psychotropic medications or rational to support continued use five (5) times a week times two (2) weeks, weekly times two (2) weeks and then monthly times two (2) months. The Nursing Home Administrator/Designee will audit for completion.

Pharmacist will audit all residents on PRN psychotropic medications for stop dates as appropriate when completing the monthly medication review.

Results of the audits will be discussed at the Quality Assurance Process Improvement.

483.70 REQUIREMENT Administration: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.
483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Observations:


Based on review of facility records and job descriptions, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to ensure adequate resident safety and supervision.

Findings include:

Review of the job description for the NHA revealed that he/she is responsible for overall facility management, profitability, operations, and direction in all aspects. Accountable for but not limited to, census development, management of accounts receivable and collections, maximization of Net Operating Income, resident/patient care, state and federal survey compliance, positive employee relations, a positive return on investment, an effective business plan and implementation of core programs. Designated the representative in the facility and community. Follows all policies and procedures. Completes rounds of entire facility premises at least daily to ensure compliance with all policies, procedures, and regulations.

Review of the job description for the DON revealed that he/she is responsible for maintaining a high standard of resident centered care and is expected to keep resident care running smoothly while staying within budget.

Based on the findings in this report that identified the facility failed to ensure adequate supervision and implement all safety interventions, the NHA and DON failed to fulfill essential job duties to ensure that the Federal and State guidelines and regulations were followed.

Refer to F689

28 Pa. Code 201.14(a) Responsibility of Licensee

28 Pa. Code 201.18(b)(1)(3) Management

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

28 Pa. Code 211.12(c) Nursing Services

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






 Plan of Correction - To be completed: 04/01/2024

The facility is be managed to effectively ensure adequate resident safety and supervision.

A new Director of Nursing has been hired and will complete all of the duties as indicated in the facility to ensure adequate resident safety and supervision in the nursing department.

The Director of Operations will educate the Nursing Home Administrator and the Director of Nursing on their job descriptions.

The Director of Operations/designee will monitor morning clinical meeting where all progress notes are reviewed; incident reports are reviewed to ensure interventions are put into place, investigations are completed appropriately, care plans are updated, physician orders are reviewed, clinical alerts are addressed, physicians are notified as needed, families are notified as needed, resident grievances/concerns are addressed, wt losses are addressed, change in conditions are addressed, psychosocial issues are and other concerns as found; follow through on clinical needs at stand down meeting in the afternoon five (5) times a week times two (2) weeks, weekly times two (2) weeks and then monthly times two (2) months.

Results of the audits will be discussed at the Quality Assurance Process Improvement.

The Director of Operations/designee will audit through monthly facility reports to ensure resident safety and supervision ongoing.

211.5(f)(i)-(xi) LICENSURE Medical records.:State only Deficiency.
(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to include the recapitulation of stay (summary of residents stay and course of treatment in the facility) with discharge summary for one of three closed records reviewed (Resident CR133).

Findings include:

Resident CR133's clinical record revealed an admission date of 5/12/23, with diagnoses that included heart failure, irregular heartbeat, encephalopathy (a group of conditions that cause brain dysfunction), Type 2 Diabetes (condition that affects how the body uses glucose (sugar)), and pancytopenia (a condition in which there is a lower-than-normal number of red and white blood cells and platelets in the blood).

Review of the clinical record revealed that Resident CR133 was transferred to the acute care hospital on 12/20/23, for evaluation and treatment of respiratory symptoms, and did not return to the facility.

Review of Resident CR133's clinical record lacked evidence of a recapitulation of Resident CR133's stay and discharge summary.

During an interview on 2/23/24, at 10:05 a.m. the Director of Nursing confirmed that Resident CR133's clinical record lacked a discharge summary and recapitulation of stay.



 Plan of Correction - To be completed: 04/01/2024

A recapitulation of stay and discharge summary will be completed on R133.

An initial audit will be completed on all residents who have discharged in the last thirty (30) days to ensure a recapitulation of stay has been completed. A capitulation of stay will be completed as needed.

All residents will have a recapitulation of stay and discharge summary when they discharge from the facility.

The medical records clerk will be trained on ensuring a recapitulation and discharge summary is completed when a resident discharges. The Nursing Home Administrator will monitor that the training is completed.

The Nursing Home Administrator will audit discharged resident to ensure a recapitulation has been completed five (5) times a week times two (2) weeks, weekly times two (2) weeks and then monthly times two (2) months. Corrections will be completed as needed.

Audits will be ongoing for all discharged residents to ensure a recapitulation has been completed. Results of the audits will be discussed at the Quality Assurance Process Improvement.


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