Nursing Investigation Results -

Pennsylvania Department of Health
SPIRITRUST LUTHERAN THE VILLAGE AT UTZ TERRACE
Patient Care Inspection Results

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SPIRITRUST LUTHERAN THE VILLAGE AT UTZ TERRACE
Inspection Results For:

There are  53 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.
SPIRITRUST LUTHERAN THE VILLAGE AT UTZ TERRACE - 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 June 9, 2022, it was determined that Spiritrust Lutheran, The Village at Utz Terrace 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:


483.60(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, document review, and staff interview, it was determined that the facility failed to ensure food is prepared and distributed in accordance with professional standards for food service safety for one of two kitchen areas reviewed (facility kitchenette).

Findings Include:

Review of the facility's policy, titled "Use of Hair Restraints" recently revised September 2021, reads "Dining service staff must wear hair restraints as a preventative measure against the spread of illness and to prevent hair from contacting exposed food."

Observations in the facility's kitchenette area on June 6, 2022, at 6:41 PM, revealed Dining Service Aides 1 and 2 performing duties without the use of hair restraints.

An inteview with the Dining Services General Manager on June 9, 2022, at 9:44 AM, confirmed staff should wear hair restraints while in the facility's kitchenette area.

28 Pa. Code 211.6 (f) Dietary services


 Plan of Correction - To be completed: 07/13/2022

Dining members were found without the required hair restraints
All staff will be reeducated on when and where hair restraints must be worn.

All new hires will be educated on the use of required hair restraints. Reminder signs will be posted regarding the areas in which hair restraints must be worn.
Managers will discuss the issue with staff during huddle meeting.

Education will be done with all new hires.

An audit will be done in the following order

2x Weekly for 2 weeks
1x Weekly for 3 weeks
Spot checks of at least twice monthly
Findings will be reported to the Quality Assurance Improvement Performance Committee.

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 interview, it was determined that the facility failed to inform each resident, in writing, of services available in the facility and charges for those services, including any charges for services not covered under Medicare A, for two of three residents reviewed (Residents 37 and 138).

Findings Include:


Review of the "Skilled Nursing Facility Beneficiary Protection Notification Review" form, completed on behalf of Resident 37, revealed a last covered day of Medicare A services as May 31, 2022.

Review of the facility's documentation revealed the facility had no information to confirm Resident 37 received the "Advance Beneficiary Notice of Non-Coverage (SNF-ABN)" form detailing the non-covered facility charges and services that may be the responsibility of Resident 37.

Review of the "Skilled Nursing Facility Beneficiary Protection Notification Review" form, completed on behalf of Resident 138, revealed a last covered ay of Medicare A services as January 26, 2022.

Review of the facility documentation revealed the facility had not reviewed or completed the required SNF-ABN, with Resident 138 or the Resident's responsible party.

An interview with the Nursing Home Administrator, on June 9, 2022, at 9:08 AM, revealed the facility's billing staff provided the information for review. No additional information was provided by the facility at the conclusion of the full health survey regarding the SNF-ABN forms for Residents 37 and 138.

28 Pa. Code 201.14 Responsibility of licensee
28 Pa. Code 211.5 (f) Clinical records


 Plan of Correction - To be completed: 07/13/2022

Facility failed to inform residents, in writing, of services available in facility, charges for services, and those not covered under Medicare A using the Advance Beneficiary Notice of Non-Coverage (SNF-ABN).
Resident #37 no longer resides in the facility. The facility has completed and provided the required SNF- ABN to resident #138/resident responsible party. Triple Check process is in place to ensure SNF- ABN is completed.
An audit of Medicaid eligible residents has been conducted to ensure eligible residents are notified in writing thru the issuance of the SNF-ABN.
Social Services/Admissions will be educated on the process of the Advance Beneficiary Notice of Non-Coverage (SNF-ABN).

The NHA or designee will audit weekly X 4, and ongoing monthly thru Triple Check process. Findings will be reported to the Quality Assurance Improvement Performance Committee.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for one of fourteen residents reviewed (Resident 26).

Findings include:

Review of Resident 26's clinical record revealed diagnoses that included diabetes mellitus (group of diseases that affect how your body uses blood sugar [glucose]) and chronic respiratory failure (a condition that results in the inability to effectively exchange carbon dioxide and oxygen).

Review of Resident 26's current Care Plan on June 7, 2022, revealed a care plan with the focus of: I have an infection of the (specify): UTI (urinary tract infection), Initiated April 28, 2022, with no revisions.

Review of Resident 26's MAR (Medication Administration Record) for the month of April 2022, revealed that Resident 26 received Cephalexin 500 mg twice daily for two days to treat an UTI.

Interview with the Nursing Home Administrator on June 9, 2022, at 11:30 AM, revealed that Resident 26's care plan should have been updated to reflect that the UTI was resolved in April 2022.

42 CFR 483.21(b) Comprehensive Care Plans.
28 Pa. Code 211.11(d)(e) Resident care plan.
28 Pa. Code 211.12(d)(5) Nursing services.


 Plan of Correction - To be completed: 07/13/2022

UTI care plan was not resolved when the infection resolved.

Resident #26 care plan for UTI has been resolved.
An audit will be conducted of resident care plans to identify and resolve care plans that are no longer applicable.
The Interdisciplinary Team will be in-serviced on the Comprehensive Care plan standard with focus on the need to revise the care plan as the resident's status changes. The Interdisciplinary Team will include a review of care plans when reviewing change in resident status and physician orders at standup.

The DON or designee will conduct a random audit of 10% of care plans weekly x4 and monthly x2. Findings will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills: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(g)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:

Based on observation, facility policy review, and staff interview, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of fourteen residents reviewed (Resident 15).

Findings include:

Review of facility policy, "Tube Feeding Standard", last revised April 1, 2016, revealed "Feeding solution is hung per manufacturer recommendations. Irrigation syringes are labeled with resident name, date, and changed daily on 11-7 shift."

Review of package insert for Jevity 1.2 cal dated June 29, 2021, revealed, "once opened use within 48 hours".

Review of Resident 15's clinical record revealed diagnoses including dysphagia (difficulty swallowing) and multiple sclerosis (disease in which the immune system eats away at the protective covering of nerves).

Review of Resident 15's current physician orders revealed a physician's order for Jevity 1.2 at 80 ml per hour continuously from 8:00 PM until 4:00 PM.

Observation of Resident 15 on June 6, 2022, at 6:34 PM, revealed that the Resident was receiving Jevity 1.2 cal at 80 ml per hour. Further observation revealed that the bottle of Jevity, tubing, and water flush bag were not labeled with a time or date that they were opened and hung at the Resident's bedside.

Interview with Nursing Home Administrator on June 9, 2022, at 11:30 PM, revealed that the Jevity should have been labeled with the date that it was opened, and the Jevity should have been being provided from 8:00 PM until 4:00 PM as ordered by the physician.

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


 Plan of Correction - To be completed: 07/13/2022

Enteral nutrition was not labeled with the date it was opened.

Resident #15 enteral nutrition was replaced with a dated bottle.
An audit was conducted to ensure the other resident's enteral nutrition was dated when opened.
The licensed nurses will be in-serviced on the Tube Feeding standard including the need to label the feeding with the date and time it was opened and hung.
The DON or designee will audit once daily for 1 week, then twice weekly x 4 weeks, then once weekly x 4 weeks. Findings will be reported to the Quality Assurance Performance Improvement Committee for review and 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 review clinical records, observations, facility policy review, and staff interviews, it was determined that the facility failed to provide respiratory services for one of fourteen residents reviewed (Resident 26).

Findings include:

Review of facility provided policy titled, "Oxygen Administration", dated 2006, revealed, "Check physician's order for the liter flow and method of administration".

Review of Resident 26's clinical record revealed diagnoses that included diabetes mellitus (group of diseases that affect how your body uses blood sugar [glucose]) and chronic respiratory failure (a condition that results in the inability to effectively exchange carbon dioxide and oxygen).

During an observation on June 6, 2022, at 6:45 PM, Resident 26 was lying in their bed. Observation of Resident 26 revealed that Resident 26 was receiving supplemental oxygen, via nasal canula, at 3 liters per minute.

Review of Resident 26's physician orders, on June 7, 2022, failed to reveal any physician's order for supplemental oxygen.

During an interview with the Nursing Home Administrator on June 9, 2022, at 11:15 AM, it was revealed that the expectation is that nurses follow the physician's orders and facility policies.

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


 Plan of Correction - To be completed: 07/13/2022

Oxygen was administered without a physician order.

Resident #26 physician has given an order to administer oxygen to the resident.
An audit will be conducted to ensure there is a physician order for residents receiving supplemental oxygen.
Licensed nurses will be in-serviced on the standard for oxygen administration.
The DON or designee will audit and conduct rounds weekly x4 then monthly x2 to ensure there is a physician's order for residents receiving oxygen.
Findings will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.








483.25(n)(1)-(4) REQUIREMENT Bedrails: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(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.
Observations:

Based on observation, document review, policy review, and staff interview, it was determined that the facility failed to ensure each resident is assessed for the risk of entrapment from bed rails prior to installation for one of five residents reviewed for the use of enabler bars (Resident 8).

Findings Include:

Review of Resident 8's clinical record revealed diagnoses including abnormalities of gait (a person's manner of walking) and mobility (the ability to move or be moved freely and easily) and muscle weakness.

An observation in Resident 8's room, on June 7, 2022, at 10:21 AM, revealed an enabler bar attached to the left of the Resident's bed.

Review of the facility's "Bed Inspection Standard", recently reviewed October 4, 2012, reads "The Bed Rail Risk Data Collection Tool... will be completed during an admission/readmission, quarterly, or when a new rail or mattress is installed."

Review of Resident 8's interdisciplinary plan of care revealed a problem area identified with the activities of daily living (ADL's - a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility). The plan of care continues with interventions including "Enablers: Left" with a date of initiation documented May 21, 2022.

Review of the facility's enabler/bed rail measurement form revealed "install left handrail" in Resident 8's room also dated May 21, 2022.

Review of the facility's "Bed Rail Risk Data Collection Tool", completed on behalf of Resident 8, reveals an assessment date for the use of the enabler bar of June 8, 2022.

An interview with the Nursing Home Adminstrator, on June 9, 2022, at 11:34 AM, revealed nursing staff complete the "Bed Rail Risk Data Collection Tool."

No additional information regarding a "Bed Rail Risk Data Collection Tool" was provided by the facility to confirm the assessment prior to the installation of the enabler bar to Resident 8's bed on May 21, 2022.

28 Pa. Code 211.5 (f) Clinical records
28 Pa. Code 211.10 (a) Resident care policies


 Plan of Correction - To be completed: 07/13/2022

The Bedrail Risk Data Collection Tool was not completed prior to installing a left enabler bar.
Resident #8 no longer resides in the facility.
An audit will be conducted of residents with enabler bars to ensure a Bedrail Risk Data Collection Tool has been completed.
Licensed nursing staff will be in-serviced on the Bed Inspection standard with focus on completion of the Bed Rail Risk Data Collection Tool.
The Interdisciplinary Team will ensure completion of the bedrail risk data collection tool when reviewing new admissions and readmissions at standup.
The NHA or designee will conduct random audit of 10% to ensure the Bed Rail Risk Data Collection Tool has been completed weekly x4 and monthly x2. Findings will be reported to the Quality Assurance Performance Improvement Committee for review and 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 review of facility policy and documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure that the pharmacy regimen review was accurately completed, and that the physician responded to and provided an appropriate rationale to the recommended changes for one of fourteen residents reviewed (Resident 31).

Findings include:

Review of facility policy titled, "Drug Regimen Review Standard" last revised November 28, 2017, revealed, "The Pharmacist will provide the DON [Director of Nursing]/designee and the Medical Director/designee a separate written report of any irregularities after each visit. The DON/designee will be responsible for the timely notification to the attending physician of any identified irregularities for response as needed. The non-urgent findings will be acted on by the next pharmacy consultant visit."

Review of Resident 31's clinical record revealed diagnoses that included diabetes mellitus (group of diseases that affect how your body uses blood sugar [glucose]) and major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).

Review of facility provided documents failed to reveal any evidence that a physician responded to the recommendations made by the consultant pharmacist in December 2021.

Interview with the Nursing Home Administrator on June 9, 2022, at 11:30 AM, revealed that the physician should be reviewing recommendations from the consultant pharmacist and responding to them prior to the next monthly visit per facility policy and regulation.

28 Pa. Code 211.2(a) Physician services
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.10(c) Resident care policies


 Plan of Correction - To be completed: 07/13/2022

Physician did not respond timely to a Pharmacy Regimen Review.

The physician responded to pharmacy consultant's recommendation for Resident #31 the following month.
An audit will be conducted to ensure the physician has responded to the most recent pharmacy consultant recommendations.
The physicians and licensed nursing staff will be in-serviced on the Drug Regimen Review standard.
The DON has implemented a tracking system to monitor the physician's response to the monthly pharmacy consultant recommendations.
The NHA or designee will audit the tracking system monthly x3. Findings will be reported to 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 surveyor observation, manufacturer information, facility documentation, and staff interview, it was determined that the facility failed to store and label medications, drugs, and biologicals in accordance with currently accepted professional principles on two of two medication carts (front hall medication cart and back hall medication cart).

Findings Include:

Observation of front hall medication cart on June 8, 2022, at 8:50 AM, revealed one open bottle of Prosource with no open date, and two open bottles of Assure dose control solution with no open date.

Review of package label for Prosource on June 8, 2022, at 8:50 AM, revealed that Prosource should be discarded three months after opening.

Review of Assure dose control solution product packaging on June 9, 2022, at 11:00 AM revealed, "Use the Assure Dose Control Solution within 90 days (3 months) of first opening. It is recommended that you write the date of opening on the control solution bottle label ("Date Opened") as a reminder to dispose of the opened solution after 90 days."

Observation of back hall medication cart on June 8, 2022, at 8:55 AM, revealed one Solostar Lantus insulin pen, unrefrigerated and open/in-use with no open date label. Further review revealed one Humalog insulin pen, unrefrigerated and open/in-use with no open date label.

Review of Humalog insulin product packaging on June 9, 2022, at 11:00 AM revealed instructions to discard in-use (opened) insulin 28 days after opening.

Review of Lantus Solostar product packaging on June 9, 2022, at 11:00 AM, revealed "Once you take your SoloSTAR out of cool storage, for use or as a spare, you can use it for up to 28 days. During this time, it should be kept at room temperature (15 - 30and must not be stored in the refrigerator. If there is any remaining insulin after 28 days, discard it."

Interview with Nursing Home Administrator on June 9, 2022, at 12:15 PM, revealed that facility employees are expected to date insulin pens and other medications when opened and dispose of them after the recommended time specified by the manufacturer, but they do not have a policy that states that.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.9(a)(1)(i) Pharmacy services
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services


 Plan of Correction - To be completed: 07/13/2022

Multi-dose medications with instructions to dispose of same within a specified time period were not dated when opened.

No specific residents were identified.
An audit will be completed of both med carts. Opened, undated medications and biologicals will be disposed of and replaced with new.
The standard will be reviewed for the dating and disposing of medications when developed. Licensed nursing staff will be educated.
The DON or designee will audit medication carts weekly x4 then monthly x2. Findings will be reported to the Quality Assurance Improvement Performance Committee.


211.6(e) LICENSURE Dietary Services.:State only Deficiency.
(e) A current therapeutic diet manual approved jointly by the dietitian and medical director shall be readily available to attending physicians and nursing and dietetic service personnel.
Observations:

Based on document review and staff interview, it was determined that the facility failed to maintain a current therapeutic diet manual approved jointly by the dietician and medical director for one of one document reviewed (Dining Services Annual Review of Diet Manual).

Findings Include:

Review of the facility's form titled "Dining Services Annual Review of Diet Manual" revealed signature dates for the dining services General Manager, dated March 9, 2022, Clinical Nutrition Manager, dated March 9, 2022, and the Nursing Home Administrator, dated March 10, 2022.

Continued review of the document revealed no signature or date for the Medical Director.

An interview with the dining services General Manager, on June 9, 2022, at 9:44 AM, revealed the document was sent to the Medical Director, at the time of the diet manual review, in March 2022 and had not been signed until June 9, 2022.


 Plan of Correction - To be completed: 07/13/2022

Diet manual was not up to date with all signatures by the required date.
All required signatures and dates obtained.
The diet manual will be reviewed as part of Quality Assurance Performance Improvement Meeting annually, with changes as needed. Advance reminders will be sent to team members when the annual process is initiated for review, signatures, and date.

The QAPI calendar will establish the annual review date and completion of all signatures and dates.


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