Pennsylvania Department of Health
MT LEBANON REHABILITATION AND WELLNESS CENTER
Patient Care Inspection Results

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MT LEBANON REHABILITATION AND WELLNESS CENTER
Inspection Results For:

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MT LEBANON REHABILITATION AND WELLNESS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated survey in response to a complaint completed on January 30, 2024, it was determined that Mt. Lebanon Rehabilitation and Wellness Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.70(a)-(c) REQUIREMENT License/Comply w/ Fed/State/Locl Law/Prof Std: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(a) Licensure.
A facility must be licensed under applicable State and local law.

§483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards.
The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.

§483.70(c) Relationship to Other HHS Regulations.
In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.
Observations:
Based on review of facility financial documents, interviews with vendors and staff, it was determined that the facility failed to pay bills in a timely manner for services without which the residents' health and safety are potentially impacted.

Findings include:

28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), dated July 1, 2023, indicated that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are jeopardized.

Review of facility provided Accounts Payable Ledger on 1/30/24, at 8:45 a.m., indicated Vendor 1 with an outstanding balance of $2,707.31 for services from October 2023, and "prior."

Interview with Nursing Home Administrator on 1/30/24, at 10:12 a.m., indicated that the facility utilizes the company for equipment such as oxygen concentrator's and specialty beds for residents requiring them. The NHA indicated that she does not review the ledger as the "Consultants pay the bills" and that the facility failed to pay bills in a timely manner for services without which the residents's health and safety are potentially impacted.


28 Pa Code: 201.14 (a)(c )(e ) Responsibility of management

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



 Plan of Correction - To be completed: 03/04/2024

1. The facility bill for Vendor 1 is under dispute. A new Vendor has been contracted by the facility to ensure no residents are affected by the bill dispute with Vendor 1.
2. A review of the facility's current rentals from the medical supply vendor was conducted to determine which items were not needed or billed incorrectly, and alternative suppliers were engaged to ensure no items needed for the health and safety of residents in question would be at risk due to timeliness and accuracy of bills incurred.
3. The facility will review the 24 hour report daily at stand up to ensure that residents have equipment needed to ensure the Health and Safety of the Residents and any concerns will be addressed at that time. Facility staff involved in ensuring equipment is available for residents will be in-serviced on utilization of the new company.
4. The Nursing Home Administrator will conduct an audit of the new equipment Vendor weekly for 4 weeks and monthly for 2 months to ensure that there are no concerns with the equipment supply chain, with results submitted to the facility Quality Assessment and Assurance Committee. Any concerns will be addressed as needed.

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