Pennsylvania Department of Health
QUARRYVILLE PRESBYTERIAN RETIREMENT COMMUNITY
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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QUARRYVILLE PRESBYTERIAN RETIREMENT COMMUNITY - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure, and Civil Rights Compliance Survey completed on July 10, 2024, it was determined that Quarryville Presbyterian Retirement Community, 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:

483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary:

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(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.

Observations:

Based on a review of clinical records and interview with staff, it was determined that the facility failed to ensure a physician's discharge summary was completed prior to or at the time of discharge for one of two closed records (Resident 83).

Findings include:

Review of Resident 83's clinical record revealed that the resident was discharged from the facility on July 2, 2024.

Further review of Resident 83's clinical record failed to reveal evidence that the discharge summary was completed by the physician prior to or at the time of discharge.

Interview with the Nursing Home Administrator on July 10, 2024 at 10:00 a.m. confirmed that the discharge summary was not completed.

28 Pa Code 211.5(d) Clinical record

Plan of Correction - To be completed: 08/13/2024

The discharge Summary for Resident #86 was completed by the resident's Primary Care Physician during the week of the survey.

The Director of Nursing / Designee will in-service all attending physicians on this regulation.

The Director of Nursing/ Designee will perform baseline audit of the discharge residents from the last 30 days.

The Director of Nursing / Designee will audit all discharged residents over the next 30 days to ensure compliance with this regulation.

The results of these audits will be submitted to the Quality Assessment / Process Improvement team for review and further recommendations.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§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 observations, clinical record reviews, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for one of four residents reviewed (Residents 2).

Findings include:

Review of the facility's policy titled "Enhanced Barrier Precautions" (EBP) dated March 2024, revealed EBP will be used in the care of any residents who are at higher risk of colonization or infection with multi-drug resistant organisms (MDROs). Use of Enhanced Barrier Precautions is a strategy for improved success for infection control and to expand on standard precautions.

Enhanced Barrier Precautions are designed to reduce the risk of transmission and/or colonization of MDROs from both recognized and unrecognized sources.

Enhanced Barrier Precautions require gowns and gloves to be worn during any high-contact resident care based on the location of the organism (i.e., urine, nares, wounds, etc..). EBP are to be used for residents who are at an increased risk of infection, including those with a known infection or colonization of a resistant organism who do not require contact precautions, and residents with chronic wounds or indwelling medical devices. It is meant to remain in place for these residents during the duration of their stay at the facility. Isolation is not required for those who have EBP in place.

Clinical records review revealed Resident 2 had a Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss) to the coccyx.

Observation conducted of Resident 2's room failed to reveal evidence of EBP signage/communication.

Interview with the Director of Nursing, Nursing Home Administrator, and Wound Nurse was conducted on July 10, 2024, at 2:10 p.m., where it was confirmed that the EBP process was not followed for Resident 2.

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

28 Pa. Code 211.5(f) Clinical records

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

Plan of Correction - To be completed: 08/13/2024

Proper signage was placed outside of Resident #2's door to inform team members and visitors to see the nurse prior to entering the room.

The Infection Preventionist / Designee will review and update the facility policies as needed for Enhanced Barrier Precautions (EBC).

The Infection Preventionist / Designee will train all licensed nursing staff of the facility policy for Enhanced Barrier Precautions.

The Infection Preventionist / Designee will perform a baseline audit of rooms with residents that have infections with multi drug resistant organisms to ensure that the facility is meeting the requirements of this regulation.

The Infection Preventionist / Designee will audit care provided to 50% of residents with multi drug resistant organisms to ensure compliance with facility policy and this regulation. This audit will be conducted weekly for 4 weeks.

The results of these audits will be submitted to the Quality Assessment / Process Improvement team for review and further recommendations.

§ 211.5(d) LICENSURE Medical records.:

(d) Records of discharged residents shall be completed within 30 days of discharge. Medical information pertaining to a resident ' s stay shall be centralized in the resident ' s record.

Observations:
Based on a review of clinical records and interview with staff, it was determined that the facility failed to ensure that a physician's discharge summary was completed within 30 days of discharge for one of two closed records (Resident 86).

Findings include:

Review of Resident 86's clinical record revealed that the resident expired in the facility on June 6, 2024. There was no evidence that the discharge summary was completed by the physician within 30 days of discharge.

Interview with the Nursing Home Administrator on July 10, 2024 at 10:00 a.m. confirmed that the discharge summary was not completed.

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

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:
Based on a review of staffing documents provided by the facility and staff interviews it was determined that the facility failed to provide one nurse assistant (NA) per 10 residents on the daylight shift for two of twenty one days July 5, 2024, and July 7, 2024 as required.

Findings include:

A review of facility staffing documents provided by the facility revealed the facility failed to provide NA on the following shifts as required:

Daylight shift:

DateCensusActual hours Hours required
July 5, 2024 84 50.82 64.80
July 7, 2024 81 50.95 64.80

During an interview on July 10, 2024, at 1:50 p.m., the Nursing Home Administrator confirmed that the facility failed to provide NA's in the facility on the above shifts as required.

Plan of Correction - To be completed: 08/13/2024

The Director of Nursing / Designee will re-educate the Staffing Coordinator of the requirements of this regulation.

The facility is unable to correct the identified staffing issues on July 5th and July 7th, 2024. Going forward the facility's leadership team will ensure that the facility meets this requirement.

The Director of Nursing /Designee will meet with the staffing coordinator Monday - Friday to review the staffing needs for the facility. When needed to meet this requirement the facility will use outside staffing agencies.

The Assistant Administrator / Designee will review nursing department staffing daily to ensure that the requirements of this regulation are met.

The results of these audits will be submitted to the Quality Assessment Process Improvement team for review and further recommendations.

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