Pennsylvania Department of Health
POCOPSON HOME
Patient Care Inspection Results

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POCOPSON HOME
Inspection Results For:

There are  121 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.
POCOPSON HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State licensure and Civil Rights Compliance Survey completed on March 22, 2024, it was determined that Pocopson Home 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 for the Health portion of the survey process.


 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 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.
§483.80 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 upon review of facility policy and procedure and observation, it was determined the facility failed to ensure adequate infection control measures occurred during medication pass observation on one of two nursing units observed (1 West).

Findings include:

Review of facility policy and procedure titled "Medication Administration", revised June 2022, revealed "nurses will wash his or her hands and apply gloves previous to administering any eye medication."

Observation of medication administration on the 1 West nursing unit on March 20, 2024, at 8:56 a.m. revealed Licensed Employee E3 removing medications from pill packs and placing the individual pills in the employee's hand before placing the medication in the medication cup. Licensed Employee E3 was not wearing gloves at that time.

Further observation of medication administration on the 1 West nursing unit on March 20, 2024, at 8:56 a.m. revealed Licensed Employee E3 did not wear gloves when administering eye medications.

Interview with the Director of Nursing on March 22, 2024, at 11:00 a.m. confirmed Licensed Employee E3 should have been wearing gloves while administering eye medication and should have placed the pills directly into the medication cup from the pill pack.

28 Pa code 201.14(a) Responsible Licensee

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




 Plan of Correction - To be completed: 04/05/2024

Employee E3 was immediately re-educated on administering medication using the proper infection control techniques. Pocopson Home Medication Administration policy will be updated to clarify infection control procedures.

An audit of 10 random medication passes will be completed weekly for 4 weeks and then monthly for 3 months. Aduit results will be reported to the QAPI committee and reviewed during quarterly QAPI meetings.

All nursing staff will be re-educated on the proper procedure for administering medications and will be educated on the infection control changes to the written policy and procedure.

Preparation and submission of the Plan of Correction is required by State and Federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding.

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:
Based on review of facility staffing data and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents on evening shift and one nurse aide per 20 residents overnight, for the weeks of September 3, 2023, and March 15, 2024.

Findings include:

Review of the weeks of September 3, 2023, and March 15, 2024, revealed the following dates on evening shift did not meet the requirement of one nurse aide per 12 residents:

September 5, 2023, March 15, 2024, and March 16, 2024.

Review of the weeks of September 3, 2023, and March 15, 2024, revealed the following dates on night shift did not meet the requirement of one nurse aide per 20 residents:

September 6, 2023, September 8, 2023, and March 16, 2024.

This information was provided to the Nursing Home Administrator and Director of Nursing on March 22, 2024, at 12:00 p.m.


 Plan of Correction - To be completed: 04/05/2024

The Director of Nursing will audit all spreadsheets showing daily scheduled staff and resident census to ensure the minimum staffing requirements are met on each shift. Aduit results will be reported to the QAPI committee and reviewed during quarterly QAPI meetings.

All nursing supervisors will be re-educated on the new staffing requirements and the implementation of those requirements in the daily schedule.

Preparation and submission of the Plan of Correction is required by State and Federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding.


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