Pennsylvania Department of Health
SIMPSON HOUSE INC
Patient Care Inspection Results

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SIMPSON HOUSE INC
Inspection Results For:

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SIMPSON HOUSE INC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on April 24, 2025, it was determined that Simpson House Inc. 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 related to the health portion of the survey process.



 Plan of Correction:


483.70(p)(1)-(5) REQUIREMENT Payroll Based Journal:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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(p) Mandatory submission of staffing information based on payroll data in a uniform format.
Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

§483.70(p)(1) Direct Care Staff.
Direct Care Staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Direct care staff does not include individuals whose primary duty is maintaining the physical environment of the long term care facility (for example, housekeeping).

§483.70(p)(2) Submission requirements.
The facility must electronically submit to CMS complete and accurate direct care staffing information, including the following:
(i) The category of work for each person on direct care staff (including, but not limited to, whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS);
(ii) Resident census data; and
(iii) Information on direct care staff turnover and tenure, and on the hours of care provided by each category of staff per resident per day (including, but not limited to, start date, end date (as applicable), and hours worked for each individual).

§483.70(p)(3) Distinguishing employee from agency and contract staff.
When reporting information about direct care staff, the facility must specify whether the individual is an employee of the facility, or is engaged by the facility under contract or through an agency.

§483.70(p)(4) Data format.
The facility must submit direct care staffing information in the uniform format specified by CMS.

§483.70(p)(5) Submission schedule.
The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly.
Observations:

Based on review of Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) staffing data report and staff interview, it was determined that the facility failed to electronically submit direct care staffing information for one of one quarter reviewed (Fiscal Year Quarter 1 2025 - October 1, 2024, to December 31, 2024).

Findings include:

According to Section 6106 of the Affordable Care Act (ACA), "facilities are required to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data. The data, when combined with census information, can then be used to report on the level of staff in each nursing home, as well as employee turnover and tenure, which can impact the quality of care delivered."

Review State Operations Manual, under section 483.70(q), revealed "Mandatory submission of staffing information based on payroll data in uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS." Under section 483.70(q)(4), "The facility must submit direct care staffing information in the uniform format specified by CMS." Under section 483.70(q)(5), "The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly."

Review of PBJ staffing data report for Fiscal Year Quarter 1 2025 - October 1, 2024, to December 31, 2024 revealed the facility triggered for "Failed to Submit Data for the Quarter."

Interview with the Director of Nursing, Employee E2, revealed no other information or documentation was available for review.

28 Pa. Code 201.18(a) Management





 Plan of Correction - To be completed: 05/30/2025

1-The Director of Nursing and
Administrator will be in-serviced on CMS, 483.70 Mandatory submission of staffing based on payroll data in a uniform format that Long Term Care facilities must electronically submit to CMS direct care staffing information according to the CMS submission schedule.

2-The Director of Nursing along with the Administrator will be reviewing the direct care staffing data monthly for electronic submission.

3- The administrator will monitor that the facility submits the direct care staffing data electronically in the uniform format for each quarter as directed by CMS for Payroll Based Journal. Data submission will be reported by the Director of Nursing or the Administrator through the Quality Assurance meeting and/ or the Facilities Governing Body meetings for compliance.
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 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 §483.71 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 review of facility policy, observations, and staff interviews it was determined that the facility failed to implement enhanced barrier precautions for four of seventeen residents reviewed (Resident R36, R50, R24, R48).

Findings Include:

Review of facility policy "Enhanced Barrier Precautions - Skilled Nursing" reviewed July 2, 2024, revealed the facility will utilize enhanced barrier precautions to prevent the spread of multidrug resistant organisms (MDRO). Enhanced barrier precautions (EBP) expand the use of personal protective equipment (PPE) beyond situations in which exposure to blood and bodily fluids is anticipated. Enhanced barrier precautions include the use of a gown and gloves during high-contact resident care activities for residents with, but not limited to, wounds and/or indwelling medical devices regardless of infection status and MDRO colonization.

Further review of facility policy revealed gloves, and gown should be available immediately outside the resident room, a waste container should be near the exit of the resident room, and EBP signage should be posted for the resident room.

Review of Resident R36's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 1, 2025, revealed the resident had an indwelling catheter (also known as foley catheter - a flexible tube placed through the urethra into the bladder to help urinate and collect urine into a drainage bag).

Review of Resident R50's quarterly MDS dated February 26, 2025, revealed the resident had pressures ulcers (an open ulcer, the appearance of which will vary depending on the stage).

Review of facility wound report dated April 13, 2025, confirmed Resident R50 had an arterial ulcer (open wounds caused by poor blood flow) on the right heel, and a stage III pressure ulcer (characterized by full thickness skin loss and visible fat tissue) on the sacrum.

Review of Resident R36's and R50's clinical records, including physician orders and comprehensive care plans, revealed no documented evidence enhanced barrier precautions were implemented in the plan of care.

Observations on April 21, 2025, at 11:00 a.m. revealed no evidence that signage was placed on Resdient R36's and R50's door to indicate that the resident's required enhanced barrier precautions. Further observations revealed no gowns or a waste container were available immediatey outside/near the exit of Resdient R36's and R50's doors.

Interview and observation on April 21, 2025, at 11:02 a.m. with Resident R36 confirmed the resident still had a catheter. When questioned, Resident R36 denied that staff wear a gown when providing care.

Interview on April 21, 2025, at 11:07 a.m. with Licensed Nurse, Employee E3, revealed the employee was unaware of any residents on the ground floor nursing unit that were on enhanced barrier precautions.

Observations on April 21, 2025, at 11:24 a.m. revealed Nurse Aide, Employee E4, was in room 013 making Resident R50's bed. When questioned, Nurse Aide, Employee E4, was unaware that Resident R50 was on enhanced barrier precautions.

Review of Resident R24's quarterly MDS dated March 27, 2025, revealed the resident had an indwelling catheter.

Observation on April 21, 2025 at 10:45 a.m. revealed no signage on Resident R24's door to indicate that the resident required enhanced barrier precautions.

Interview on April 21, 2025, at 10:45 a.m. with Resident R24 confirmed the resident still had a catheter and Resident R24 and family member denied that staff wear a gown when providing care.

Review of Resident R48's quarterly MDS dated March 30, 2025, revealed the resident had an indwelling catheter.

Observation on April 21, 2025 at 10:55 a.m. revealed no signage on Resident R48's door to indicate that the resident required enhanced barrier precautions.

Interview on April 21, 2025, at 10:57 a.m. with Resident R48 confirmed the resident still had a catheter.

Further observations revealed no gowns were available immediately outside of Resident R24's and R48's doors.

Interview on April 21, 2025, at 11:10 a.m. with Unit Manager, Employee E5, confirmed no enhanced barrier precaution signage was posted on Resident R24's and Resident R48's doors and no gowns were immediately available outside Resident R24's and Resident R28's doors.


28 Pa. Code 211.10 (d) Resident care policies.

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







 Plan of Correction - To be completed: 05/30/2025


1- Residents R36, R50, R24, R48 were all placed on Enhanced Barrier Precautions. This includes PPE immediately available outside of the resident's room and a waste container near the exit of the room with signage posted for each resident's room.

All residents will be screened during the admissions process for the need of Enhanced Barrier Precautions prior to admission to the facility. The Director of Nursing/Designee will review the new orders report to determine if Enhanced Barrier Precautions needs to be initiated and added to a resident's plan of care.

All licensed staff will be educated on the policy and procedures of Enhanced Barrier Precautions and the location of where PPE will be readily available on the nursing units.

The Director of Nursing/Designee will perform random weekly audits times 4 then monthly audits times 4 then quarterly audits times 4 to assure the facility has implemented Enhanced Barrier Precautions for the required residents. Audit results will be reported by the Director of Nursing/Designee through the Quality Assurance meeting and/ or the Facilities Governing Body meetings for compliance.

Date of Corrective action May 30,2025



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 of clinical record, observations, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care related to oxygen therapy for one of two residents reviewed receiving oxygen therapy (Resident R45)

Findings include:

Clinical record review revealed Resident R45 was admitted to the facility on March 01, 2025 with a diagnoses that included pulmonary hypertension (type of high blood pressure that affects the arteries in the lungs and the right side of the heart), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), and chronic respiratory failure (not enough oxygen or too much carbon dioxide in the body) .

Review of Resident R45's physician orders, dated March, 2025, revealed an order for "oxygen 1 Liter via nasal cannula continuous to maintain spo2 (blood oxygen level) above 92%".

Observation on April 21, 2025 at 11:05 a.m. revealed Resident R45 was being administered 2 liters of oxygen via nasal cannula and Resident R45's oxygen tubing was not dated.

Continued observation on April 22, 2025 at 12:45 p.m. revealed Resident R45 continued to have 2lLiters of oxygen being administered via nasal cannula and Resident R45's oxygen tubing was not dated.

Interview on April 22, 2025 at 12:48 p.m. with Licensed nurse, Employee E3 confirmed Resident R45's oxygen concentrator was set at 2 liters and was being administered via nasal cannula and Resident R45's oxygen tubing was not dated.


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







 Plan of Correction - To be completed: 05/30/2025

1-Resident R45's oxygen concentrator setting was placed at 1 Liter as ordered by the physician. The oxygen tubing was changed and dated.

2-All residents' oxygen concentrator settings have been evaluated and are administering the proper liters of oxygen according to the physician orders. All Oxygen tubing's were changed and dated. All residents on Oxygen will receive physician orders to change and date oxygen tubing weekly.

3-All licensed staff will be re-educated on physician's orders and concentrator settings. The Director of Nursing/Designee will review the new orders report for oxygen orders and accurate concentrator settings.

4-The Director of Nursing/Designee will perform random weekly audits times 4 then monthly audits times 4 then quarterly audits times 4 of physician's orders for oxygen orders and for accurate concentrator settings. Audit results will be reported by the Director of Nursing/Designee through the Quality Assurance meeting and/ or the Facilities Governing Body meetings for compliance.

5-Date of Corrective action May 30,2025



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