Pennsylvania Department of Health
RYDAL PARK OF PHILADELPHIA PRESBYTERY HOMES INC
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

RYDAL PARK OF PHILADELPHIA PRESBYTERY HOMES INC
Inspection Results For:

There are 92 surveys for this facility. Please select a date to view the survey results.

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RYDAL PARK OF PHILADELPHIA PRESBYTERY HOMES INC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, and State Licensure Survey, completed on May 6, 2024, it was determined that Rydal Park of Philadelphia Presbytery Homes, was not in compliance with the 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 related to the health portion of the survey process.

Plan of Correction:

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 clinical records, review of facilitypolicy and interview with staff, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan related to respiratory care for one of 21 residents reviewed. (Resident R102)

Findings include:

Review of facility's policy 'Care Plans, Comprehensive Person-Centered,' indicates that "the comprehensive, person-centered care plan will: 8 (e) describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being."

Review of Residents R102's clinical record indicated admission date of April 18, 2024, with the diagnoses of encounter for screening for respiratory tuberculosis other specified symptoms and signs involving the circulatory and respiratory system, nasal congestion. A physician order dated April 18, 2024 revealed " Ipratropium -Albuterol Solution 0.5-2.5 (3) Mg/ML Order summary 1 vial inhale orally two times a day for wheezing/chest congestion".

Observation conducted on May 1, 2024, at 2:20 p.m. of Resident R102 revealed that the resident had a nebulizer machine next to his bedside. On May 3, 2024, at 9:47 a.m. an observation with a Director of Nursing, Employee E2 confirmed that Resident R103 has the nebulizer was receiving a active treatment during the observation. A review of the comprehensive care plan dated April 18, 2024, did not include a nebulizer treatment. Director of Nursing was able to confirm that the resident's comprehensive care plan was not revised to include the nebulizer treatment.

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

Plan of Correction - To be completed: 06/12/2024

POC for survey end 5/6/24:
Preparation and execution of this Response and Plan of Correction does not constitute an admission or agreement by HumanGood/Rydal Park Health Facility of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies and Plan of Correction. The Plan of Correction is being prepared and/or executed solely because it is required by State and Federal Law. For the purposes of any allegation that the facility is not in substantial compliance with Federal requirements of participation, the Response and Plan of Correction constitutes the facility's allegation of compliance in accordance with section 7305 of the State Operations Manual.

Resident R102 was discharged from the community on 5/13/2024.

Care plans of residents who have orders for a nebulizer treatment have been reviewed for accuracy.

Staff educator and/or designee is reeducating IDT team and nursing supervisors/unit managers on care plans relating to nebulizer treatments.

DON or designee will conduct weekly audits x 3 months of developed care plans to ensure care plan reflects the use of nebulizer treatments as indicated.

Results of audits will be reviewed at monthly QAPI x 3 months.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on a review of clinical records, review of facility policy and staff interviews, it was determined that the facility failed to follow physician orders related to congestive heart failure protocol for one of eight sampled residents (Resident R 72) to monitor resident's daily weights and notify the medical doctor if any weight gain.

Findings include:

Review of facility policy titled "Heart Failure-Clinical Protocol" revised November 2018, revealed that the physician identifies individuals with a history of heart failure and the nurse with assess and document. The physician will review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights, renal function, digoxin level, etc.) to monitor and when to report the finding to the physician.

Review of Resident R72's clinical record revealed that Resident R72 was admitted to the facility on December 1, 2020 with the diagnoses of acute embolism and thrombosis of auxiliary vein (blood clots in the upper arm), Type 2 diabetes (blood sugar or glucose is too high), hyperlipidemia (high cholesterol), hypertension (high blood pressure), anxiety (condition marked by extreme anxiety or panic), malignant neoplasm of breast (metastatic breast cancer), and chronic diastolic heart failure(congestive heart failure).

Continued review of Resident R72's April and May 2024 physicians orders revealed an order to weigh daily for CHF (congestive heart failure) protocol, weigh resident before breakfast, notify MD (medical doctor) of weight gain of two pounds in twenty-four hours or five pounds in one week.

Review of the resident's clinical record revealed no documented evidence that the resident was weighted daily before breakfast as ordered by the physician.

Interview with Director of Nursing, Employee E2 on May 5, 2023, at 12:40 p.m. confirmed that the weights were not documented but believed that there was documentation elsewhere. The facility was no able to submit documentation related to daily weights obtained for Resident R72 for review.

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

Plan of Correction - To be completed: 06/12/2024

Resident R72's physician order for daily weights has been reviewed and updated.

Physician orders related to daily weights will be reviewed, clarified and updated where indicated.

Staff educator and / or designee will reeducate the licensed nursing staff and Certified Nursing Assistants on obtaining daily weights. Licensed nursing staff will also be reeducated to notify the physician of weight variances within the given parameters. Licensed nursing staff will document refusal in treatment administration record where appropriate. Refusal behavior of daily weight will be care planned when appropriate.

DON or designee will conduct weekly random audits x 3 months of resident orders for those that have daily weights to ensure obtaining the weight is documented and refusal of weight is documented and physician notification where applicable.

Results of audits will be reviewed monthly at QAPI x 3 months.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§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, facility documentation, review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that a resident's wander guard was functioning for the resident who is at risk for elopement for one of the one resident reviewed (Resident R89 and failed to ensure hot beverage temperatures were monitored on one of three nursing units (3rd floor dining room).

Findings include:

Review of the facility "Wandering and Elopements" policy, last revised March 2019, indicated that " the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

Review of Residents R89s clinical record revealed that the resident was admitted to the facility on November 8, 2023, with the diagnoses of Alzheimer's diseases and unspecified dementia without behavioral disturbance, psychotic disturbance mood disturbance and anxiety.

Review of Residents R89's quarterly MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated January 29, 2024, revealed Resident 89's BIMS score was 4 (Brief Interview for Mental Status- a tool to assess cognitive function; a score of 4 indicates that the resident's was cognitively impaired).

A further review of the clinical record indicated that Resident R89 had a physician order dated March 20, 2024,
"check wanderguard (device place on wrist or ankle which automatically activates a locking mechanism system to lock doors when the resident approaches the exit doors) and proper placement every shift." A comprehensive care plan-initiated April 4, 2024, indicated "The resident is an elopement risk r/t (related to) disoriented to place, impaired safety awareness." Under interventions further stated " Device noted please monitor for function/placement and skin integrity impairment while device in use."

On May 1, 2024, at 10:52 a.m. Resident R89 was observed wearing a wanderguard on his left wrist. A registered nurse, unit manager Employee E5 tried testing the wanderguard for functionality with the wanderguard testing equipment and it wasn't screening that the wanderguard was functioning. Resident R89 and Employee E5 walked towards the elevator to test the functionality of the device and the resident's wanderguard did not function to alert the staff that Resident R89 was exiting the nursing unit. Employee E5 confirmed that the wanderguard was not functioning and needed a replacement.

Review of facility policy "Safety of Hot Liquids", revised October 2014, revealed appropriate precautions will be implemented to maximize choice of hot beverages while minimizing the potential for injury. Further review of facility policy revealed appropriate interventions will be implemented to minimize the risk from burns such as maintaining a hot liquid serving temperature of not more than 180 degrees Fahrenheit. Food service staff will monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding.

Review of facility documentation revealed an in-service conducted for nursing staff for "Heating of Food/Liquids" dated 2/6/24 and 2/7/24. Review of in-service documentation revealed nursing staff may not reheat food for residents. Dietary is responsible to take temperatures.

Observations on May 3, 2024, at 12:12 p.m. in the 3rd floor dining room revealed Dietary Aide, Employee E13, heating up a beverage in the microwave. Further observations revealed when the beverage was done in the microwave, Dietary Aide, Employee E13, took the mug out of the microwave and handed it back to the nurse aide without checking the temperature first.

Subsequent interview on May 3, 2024, at 12:15 p.m. with Dietary Aide, Employee E13, confirmed the employee did not check the temperature of the water heated in the microwave before giving it back to the nurse aide for distribution to the resident.

28 Pa. Code: 201.14(a) Responsibility of licensee.

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

28 Pa. Code: 207.2(a) Administrator's responsibility.

Plan of Correction - To be completed: 06/12/2024

Wanderguard:

Resident R89 wanderguard was immediately replaced on 5/1/24 during active survey.

Residents identified to have wanderguards have been checked for proper function of wanderguard.

Wanderguard orders have been reviewed to check for placement and function per physician order.

Staff educator and/or designee will reeducate licensed nursing staff on placement, function and checks of wanderguard.

DON and/or designee will conduct random weekly audits x 3 months of residents' orders for wanderguard placement, function and checks.

Results of audits will be reviewed monthly at QAPI X 3 months.

Hot Beverages:

Employee E13 has been reeducated on not reheating beverages in the microwave.

Culinary Director and/or designee will reeducate dining staff on not reheating beverages in the microwave.

Staff Educator will educate nursing staff on not reheating beverage in the microwave.

Culinary Director and/or designee will conduct random weekly audits x 3 months during meal service to ensure beverages are not being reheated in the microwave.

Results of audits will be reviewed monthly at QAPI x 3 months.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§483.25(g) Assisted nutrition and hydration.
(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)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Observations:

Based on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to monitor and modify interventions consistent with the resident's needs to maintain acceptable parameters of nutritional status for one four residents reviewed for nutritional status (Resident R39).

Findings Include:

Review of facility policy "Weight Assessment and Intervention", revised March 2022, revealed undesirable weight change is evaluated by the treatment team whether or not the criteria for "significant" weight change have been met. The evaluation includes, but not limited to, the resident's target weight range, and the resident's calorie, protein, and other nutrient needs compared with the resident's current intake.

Review of Resident R39's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 4, 2024, revealed the resident was admitted to the facility on April 2, 2024, and had diagnoses of dementia and malnutrition.

Review of Resident R39's nutrition assessment dated April 3, 2024, by Registered Dietitian, Employee E3, revealed the resident was at risk for dehydration and development of pressure ulcers. Resident R39 was identified as underweight related to variable intakes, dementia, and need for assistance with meals. Weight goal for Resident R39 was identified as a range between 104 to110 pounds. Interventions included to monitor weight monthly/weekly.

Review of Resident R39's weight history revealed the resident was weighed at 107 pounds on admission on April 2, 2024. Further review of Resident R39's weight trend revealed the resident was weighed at 99.8 pounds on April 10, 2024, and April 11, 2024, reflecting a significant weight loss of 6.7% and 7.2 pounds over 9 days. Resident R39 maintained a weight between 99.8 pounds and 100.4 pounds through April 24, 2024.

Review of Resident R39's entire clinical record revealed no documented evidence the Registered Dietitian was made aware of the significant weight loss. Further review of Resident R39's clinical record revealed no documented evidence the Registered Dietitian monitored the resident's weekly weights and modified/reassessed the resident's needs consistent with the significant weight loss.

Interview on May 3, 2024, at 11:45 a.m. with Registered Dietitian, Employee E3, confirmed Resident R39's significant weight loss was not assessed.

28 Pa. Code 211.10 (c) Resident care policies

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

Plan of Correction - To be completed: 06/24/2024

Resident R39 was discharged on 5/2/24.

Resident weekly weights for past 30 days have been reviewed to ensure there are no further unidentified significant weight loss without documentation or intervention where indicated.

Regional Dietitian to reeducate staff dieticians as well as covering dietitians on monitoring resident's weekly weights and modifying/reassessing of resident's dietary needs where indicated.

Staff Educator and/or designee will reeducate licensed nursing staff on the need to document in clinical record of notification of significant weight loss to the dietitian.

Dietary Manager and/or designee will conduct weekly random audits x 3 months to ensure they are no unidentified significant weight losses without documented reassessment.

DON and/or designee will conduct weekly random audits x 3 months on notification to dietitian related to significant weight loss.

Results of audits will be reviewed monthly at QAPI x 3 months.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

§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 clinical record review and staff interviews, it was determined that the facility failed to ensure a resident's medication regimen was free from potential unnecessary medications for one of five residents reviewed. (Resident R 72).

Findings include:

Review of Resident R72's clinical record revealed that Resident R72 was admitted to the facility December 1, 2020. Resident R 72 has diagnosis' including acute embolism and thrombosis of auxiliary vein (blood clots in the upper arm), Type 2 diabetes ((blood sugar or glucose is too high), hyperlipidemia (high cholesterol), hypertension (high blood pressure), anxiety (condition marked by extreme anxiety or panic), malignant neoplasm of breast (metastatic breast cancer), and chronic diastolic heart failure (congestive heart failure).

Review of Resident 72's clinical record revealed a physician order dated March 29, 2024, for Alprazolam (a psychotropic medication belonging to the class called benzodiazepine, is a fast acting tranquilizer used to treat anxiety disorders) 0.5 milligrams give one tablet by mouth every 8 hours as needed for anxiety.

Review of Resident R72's MAR (Medication Administration Record), revealed that the resident received the medication Alprazolam on 4/5/2024, 4/12/2024, 4/14/2024, 4/19/2024, and 4/26/2024.

Review of a pharmacy consultant review dated November 7, 2023 revealed a recommendation "Per CMS regulations PRN (as needed) anxiolytic orders need a fourteen day stop date, however if a duration date greater then 14 days is needed, the order will need 1) a duration for use AND 2) a clinical rationale. Please include the duration for use and rationale for the following order: Alprazolam 0.5 mg PRN." Further review of this pharmacy consultant review revealed a nurses note that the medication Alprazolam was discontinued February 9, 2024, restarted March 23, 2024 and discontinued May 3, 2024.

Review of clinical records revealed no evidence that the practitioner/ physician documented the rational and indicated the duration of the PRN order when the PRN order for Alprazolam was continued beyond 14 days.

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

Plan of Correction - To be completed: 06/12/2024

Resident R72 PRN medication was discontinued on 5/3/24.

Residents identified to have a PRN psychotropic medication order have been reviewed to ensure that a 14 day stop date is identified.

Staff educator and/or designee will reeducate the licensed nursing staff on 14 day stop date for PRN psychotropic medications.

DON/NHA will educate prescribing physicians and CRNP's on the 14 day stop date requirement for PRN psychotropic medications.

Director of Nursing and/or designee will conduct weekly random audits x 3 months to ensure PRN psychotropic medications reflect a 14 day stop date.

Results of audits will be reviewed monthly at QAPI x 3 months.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§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 review of the facility policy, observation, and staff interview, it was determined that the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with professional standards, and to discard expired medications in accordance with professional standards, for one of four medication carts observed (Middle Cart of Second Floor).

Findings include:

Review of the facility policy on Medication Labelling and Storage revised in February 2023; indicated; "multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial".

Observation of the Middle Cart of Second Floor, on May 6, 2024, at 10:31 a.m., revealed; the following opened eye medicines without marking any opened date on those medication vials:

An opened 5 ML bottle of Tobramycin Ophthalmic Solution (used to treat eye infections), with expiry date, June 2025; two opened 15 ML bottles of Alcon Tears Lubricant Eye Drop (used to dry eye), with expiry date, May 2026; an opened 5 ML bottle of Polymyxin B Sulfate and Trimethoprim Ophthalmic Solution (used to treat eye infection), with an expiry date of October 2025; an opened 5 ML bottle of Latanoprost Ophthalmic Solution (used to treat glaucoma, a condition in which increased pressure in the eye can lead to gradual loss of vision), with an expiry date of October 2025; an opened box of Systane Lubricant Eye drops Convenient single vials on the Go (used to treat dry eyes), with an expiry date of March 2025; and an opened 5 ML bottle of Brimonidine Tartrate/Timolol Maleate Ophthalmic Solution (used to treat high pressure inside the eye due to glaucoma), with an expiry date of September 2025.

Interview with Registered Nurse (RN), Employee E9, at the time of the finding, confirmed; the eye drops bottles should have been discarded, as those eye drops vials had not been marked with the opened- dates, per the facility policy.

28 Pa Code 201.14(a) Responsibility of licensee

28 Pa Code 211.9(g)(h) Pharmacy services

28 Pa Code 211.12(c) Nursing services

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

Plan of Correction - To be completed: 06/12/2024

Identified eye drops on Middle Cart of second floor have been replaced with new eye drops and dated with opened date.

Medication Carts have been audited in regards to Eye drops for proper labeling and dating and discarded where indicated.

Staff educator and/or designee will reeducate the licensed nursing staff on Medication Labeling and Dating.

DON and/or designee will conduct weekly random audits x 3 months of med carts to review eye drops to ensure proper labeling and dating procedures are being followed.

Results of audits will be reviewed monthly at QAPI x 3 months.

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 observation, and interviews with staff, it was determined that the facility failed to maintain an effective infection control program, related to the processing of linens.

Findings include:

Observation at the Laundry room of the facility on May 6, 2024, at 9:34 a.m., revealed that one Laundry Aide, Employees E10, processing and folding clean linens for the use of residents, but letting the downward end of the linen dragging on the floor of the Laundry Room. At the time of the finding interviewed Employee E10, confirmed that the linen should have been folded without letting it drag on the floor of the Laundry Room, to prevent contamination and to maintain infection control.

Observation at the Laundry room of the facility, on May 6, 2024, at 9:42 a.m., revealed that one Laundry Aide, Employees E12, was processing and folding clean linens for the use of residents, by holding the linens letting it to touch the Laundry Aides' personal clothing. At the time of the finding interviewed with Employee E12, confirmed that the linen should have been folded without letting it touch the employee's clothing to prevent contamination and to maintain infection control.

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

28 Pa Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 06/12/2024

Employees E10 and E 12 have been reeducated on Infection Control: Laundry and Linen.

Environmental Services Manager and/or designee will reeducate the team members assigned to the laundry department on Infection Control as it relates to Laundry and Linen.

Environmental Services Manager and/or designee will conduct random audits x 3 months to ensure laundry team member are following proper infection control procedures as it relates to folding clean laundry.

Results of audits will be reviewed monthly at QAPI x 3 months.

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