Nursing Investigation Results -

Pennsylvania Department of Health
RIVER VIEW NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

RIVER VIEW NURSING AND REHABILITATION CENTER
Inspection Results For:
There are 120 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.


RIVER VIEW NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid recertification, State Licensure, Civil Rights Compliance and Abbreviated Complaint survey completed on October 29, 2021, it was determined that River View Nursing and Rehabilitation Center 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.

Plan of Correction:

483.10(e)(2) REQUIREMENT Respect, Dignity/Right to have Prsnl Property:

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.

§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.

Observations:
Based on observations and interviews it was determined that the facility failed to ensure that residents had consistent and timely access to their personal laundry and clothing.

Findings included

During a tour of the facility laundry area October 27, 2021 at approximately 12:30 P.M. revealed, in the soiled area, four large bins of dirty resident personal laundry were observed.

On the clean side of the laundry department, there were multiple plastic bags of clean resident laundry pilled up next to the dryers. Next to the stack of bags of clean resident laundry, there was a large bin of clean resident laundry. Next to this clean area were three covered rolling racks filled with clean resident clothing. There were multiple bins filled with clean, unmatched socks.

During an interview at the time of the observation, Employees 3 (laundry aide) and 4 (laundry aide) stated that they both wash the linens and towels. They stated that neither of these employees process residents' personal clothing stating that there is another laundry employee that launders the residents' personal laundry. Employee 3 and 4 (laundry aides) stated that the observed resident clothing in the multiple bins and bags had been in the laundry department for a week and not returned to the residents. Employees 3 and 4 confirmed that the clean resident clothing had not been delivered to residents for at least a week.

The facility failed to ensure that residents' had consistent access to their personal possessions, their personal clothing and laundry and allow the residents to maintain a dignified personal appearance.

28 Pa. Code 201.29 (j) Resident rights

Plan of Correction - To be completed: 12/14/2021

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Soiled rooms were cleaned immediately when notified. Residents' laundry was separated, cleaned and processed. Employees 3 & 4 have bee re-educated on cross training for linens and personal clothing.

2. Housekeeping Supervisor and/or Designee will conduct and initial audit to verify that soiled and clean utility rooms are deep cleaned, and waste is removed. They will also verify that resident's personal laundry has been separated and delivered to the residents room timely.

3. Housekeeping Supervisor and/or Designee will re-educate housekeeping staff to proper cleaning and daily rounding routines of solid and clean utility rooms. They will also re-educate laundry to personal clothing schedule of cleaning and delivery to the proper floors.

4. Housekeeping Supervisor and/or Designee will conduct random audits weekly for four weeks and then monthly for two months thereafter that solid and clean utility rooms are deep cleaned, and waste is removed. They will also conduct random audits that residents personal laundry has been separated and delivered to the residents room timely. The Quality Assurance Performance Improvement committee will review findings and make changes as needed.

483.30(a)(1)(2) REQUIREMENT Resident's Care Supervised by a Physician:

§483.30 Physician Services
A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs.

§483.30(a) Physician Supervision.
The facility must ensure that-

§483.30(a)(1) The medical care of each resident is supervised by a physician;

§483.30(a)(2) Another physician supervises the medical care of residents when their attending physician is unavailable.

Observations:

Based on clinical record review and staff interview it was determined that the facility failed to ensure that each resident's care is supervised by a physician for two residents out of 23 sampled (Residents 56 and 63).

Findings include:

A review of the clinical record revealed that Resident 56 was admitted to the facility June 29, 2021, with diagnoses that included diabetes and dementia. From her date of admission to the facility to through October 25, 2021, Resident 56's attending physician was identified as Employee 8 (Physician).

Further review of the clinical record of Residents 56 revealed no documented evidence that the resident's attending physician had conducted a physical exam of these residents, held virtual health visits with the residents or had entered documentation in the residents' clinical/electronic health record in the last year.

Clinical record review revealed that Resident 63 was admitted to the facility October 20, 2020 with diagnoses that included diabetes and chronic kidney disease. From the time of admission to the facility to the time of the survey ending October 29, 2021, Resident 63's attending Physician was Employee 8.

Further review of the clinical record of Residents 63 revealed no documented evidence that the resident's attending physician had conducted a physical exam of these residents, held virtual health visits with the residents or had entered documentation in the residents' clinical/electronic health record in the last year. There was documentation of a physician's progress note on July 2, 2021 and September 12, 2021, but it was not completed by Resident 63's attending physician.

Further review of the residents' clinical records conducted during the survey ending October 29, 2021, revealed that these residents had only received the services and visits from contracted physician extenders, nurse practioners and physicians assistants, who had seen the residents on an as needed basis over the last 12 months.

During an interview October 28, 2021 at 1 PM, the Director of Nursing (DON) confirmed that Employee 8 had not provided physician services to the above residents in the last 12 months. The Nursing Home Administrator (NHA) stated that a complaint was lodged with the facility regarding Resident 56 not receiving physician care. The complaint requested a change in physician services for Resident 56. The facility's investigation revealed that Employee 8 (physician) was responsible for only two residents in the facility, Residents 56 and 63. She stated that the facility's medical records worker was out on leave for the past 4 months and the failure of Employee 8 to provide physician services to these two residents "was missed." She further stated that the two physician visits to Resident 63 in July 2021 and September 2021 were performed because Employee 8 (physician) had not seen his residents in the facility.

The NHA stated that the residents' telephone physicians orders, monthly recapped physicians orders and any other medical records that require a physician signature indicating were mailed by the facility's medical records staff to the doctor's office, signed and mailed back to the facility for the medical records department to scan into the electronic medical record.

There was no physician documentation in clinical records of Residents 56 and 63' clinical records to indicate hat Employee 8 (Physician) had provided care and services to the above mentioned residents during the last year.

28 Pa Code 211.2 (a) Physician services

28 Pa. Code 201.18(e)(1)(2)(6) Management

Plan of Correction - To be completed: 12/14/2021

1. Resident 56 and 64 were seen by the physician and their visits are up to date.

2. Medical Records and/or Designee will conduct an initial audit to verify that physician's visits are current.

3. Attending Physicians and Medical Records will be re-educated on proper visits being done time (Medical Records will be educated to notify the Nursing Home Administrator of any physician visits over due).

4. Medical Records and/or Designee will conduct random audits weekly for four weeks and then monthly for two months thereafter to verify that physician's visits are current. The Quality Assurance Performance Improvement committee will review findings and make changes as needed.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observation and staff interview, it was determined that the facility failed to provide housekeeping services to maintain a clean, sanitary and orderly environment on two of three resident units.

Findings include:

Observation October 27, 2021, at approximately 11 AM on the second floor, in room 243, revealed that the the floor of the room was littered with food, paper debris, and dirt. Liquid stains were observed on the floor and the floor was sticky to touch.

Observation in resident room 235, revealed that the garbage can was overflowing. The floor was littered with food, paper debris and dirt, along with liquid stains. The floor was sticky. as The floor of the resident's bathroom was littered with used tissues and toilet paper on the floor, as well as, dirt and liquid stains observed on the floor. There was a pair of wet underwear in the sink of the resident's bathroom.

In resident rooms 238, 239 and 230 food and paper debris, dirt and liquid stains were observed on the floor and the floor was sticky to touch, as the surveyor's feet were sticking to the floor.

Observation of the second floor shower/bathroom area on October 27, 2021 at 11:15 AM revealed a brown substance coating the grout at both the top, and the bottom on the lower wall tiles, where the wall meets the floor surrounding the entire shower room area. The garbage can in the sink/toilet room was overflowing. The floor dirty, littered with paper debris and sticky.

Observation of the first floor "COVID-19" isolation unit October 27, 2021, at approximately 1:00 P.M. revealed in resident room 109, a large amount of smeared food on the floor along with paper debris and dirt. The bathroom floor was dirty and sticky.

In resident room 101, the floor was sticky, dirty and littered with paper.

The floor of the hallway floor was sticky, stained and dirty.

Multiple plastic garbage bags filled with trash were pilled up directly on the floor of the soiled utility room. There was a large garbage bin over flowing with bagged trash. There was a large red trash can filled with plastic bags of trash with cardboard boxes placed on top of the bin. There were multiple empty cardboard boxes directly on the floor. There were four used (dirty) oxygen concentrators located next to the bags of trash. There was a suction machine with a nebulizer (respiratory treatment machine) on top of the trash bags.

The specimen refrigerator could not be accessed due to the piled up trash. The floor was was dirty, littered with trash, liquid stains and dirt. Upon entering the room there was a strong foul odor detected.

During an interview at the time of the observation, Employee 1, nurse aide, stated that housekeeping has not come to clean the COVID-"RED" first floor quarantine unit for "at least a week." She further stated that the trash has not been picked up in a week.

During an interview October 27, 2021 at approximately 1:45 PM with the contracted Housekeeping Service Regional Manager, he stated that no residents were housed on the first floor "COVID-19" unit. At the time of the observations on October 27, 2021, there were six residents residing on the unit. He then stated that Employee 2, a contracted temporary housekeeping manager from a sister facility, was assigned as the housekeeper to clean the first floor COVID unit.

However, during an interview October 27, 2021 at 1:40 P.M. Employee 2 (housekeeping manager) stated that he was not assigned to clean the COVID first floor unit to clean. He stated that he was temporarily assigned to the facility as a floor tech to clean the facility floors.

During a tour of Cyprus NURISNG Unit on October 27, 2021, at 11:45 AM, Resident 101's fall mats were observed to be visibly dirty with food and debris. The floor was visibly dirty and littered with used tissues and papers scattered throughout. The bottom bed sheet of Resident 56's bed was soiled with a red substance and was unfastened and falling off her bed, which exposed the plastic mattress cover. Also, the bottom bed sheet of Resident 104's bed was not fully fastened on her bed that exposed the plastic mattress cover. Resident 80's privacy curtain room divider was soiled and the floor was visibly dirty with dirt and debris.

Interview with the Director of Nursing (DON) on October 27, 2021, at 1:50 PM, confirmed that the facility was to be maintained in a clean and sanitary manner.

28 Pa Code 207(2)(a) Administrators responsibility

Plan of Correction - To be completed: 12/14/2021

1.The facility addressed the issues that were identified during the survey.

2.Housekeeping Supervisor or Designee will conduct an initial audit to verify that the hallways, resident rooms and shower rooms floors are clean and free from debris. They will also audit the garbage in these areas and the solid utility room to verify that it has been taken out according to the garbage schedule.

3.Nursing Home Administrator will re-educate the housekeeping department on maintaining floor care and maintaining the garbage schedule.

4.Housekeeping Supervisor or Designee will conduct random audits weekly for four weeks and the monthly for two months thereafter to verify that the hallways, resident rooms and shower rooms floors are clean and free from debris. They will also audit the garbage in these areas and the solid utility room to verify that it has been taken out according to the garbage schedule. The Quality Assurance Performance Improvement committee will review findings and make changes as needed.

483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months:

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.

§483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.

Observations:
Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined the facility failed to ensure timely completion of a quarterly Minimum Data Set Assessment of one out of 23 residents reviewed (Resident 4).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that an admission MDS assessments were to be completed no later than 14 days following admission, and Quarterly assessments to be completed no later than the ARD date (Assessment Reference Date (ARD) refers to the last day of the observation \ period that the assessment covers for the resident) plus 14 calendar days.

A Review of Resident 4's clinical record revealed a quarterly MDS assessment, with an assessment reference date of September 24, 2021. Further review of the MDS Assessment revealed that this MDS assessment was not completed until October 26, 2021.

An interview with the Director of Nursing on October 28, 2021, at approximately 10:00 AM confirmed that the facility failed to timely complete MDS assessments.

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.5(f) Clinical records.

Plan of Correction - To be completed: 12/14/2021

1.Resident 4s quarterly MDS cannot be retroactively corrected.

2.Registered Nurse Assessment Coordinator and/or Designee will conduct an initial audit to very that MDS assessments in the last 30 days are done timely.

3.Interdisciplinary Team will be re-educated by the Nursing Home Administrator on proper timely submissions of MDS assessments.

4.Registered Nurse Assessment Coordinator and/or Designee will conduct a random audit weekly for four weeks and then monthly for two months thereafter to very that MDS assessments are done timely. The Quality Assurance Performance Improvement committee will review findings and make changes as needed.

483.70(o)(1)-(4) REQUIREMENT Hospice Services:

§483.70(o) Hospice services.
§483.70(o)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

§483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

§483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

§483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24.

Observations:

Based on clinical record review and staff interview, it was determined facility failed to ensure coordination of Hospice services with facility services to meet each resident's needs for one out of two residents reviewed (Resident 78)

Findings include:

A review of the clinical record revealed that Resident 78 was admitted to the facility on September 3, 2021, with diagnoses of myotonic dystrophy [is a type of muscular dystrophy, a group of genetic disorders that cause progressive muscle loss and weakness and muscles are often unable to relax after contraction] and malignant neoplasm of the eye [cancer of the eye].

On September 3, 2021, at 8:58 PM, the physician ordered a hospice consult for the resident.
There was no physician order in the resident's clinical record to begin hospice services.

Review of resident 78's care plan dated September 21, 2021, indicated that the resident was receiving hospice services due to myotonic muscular dystrophy and exacerbation of COPD. The goal was that Resident 78' end of life care be coordinated with the facility and hospice agency.

Further review of Resident 78's comprehensive person-centered care plan revealed that the resident's plan of care was not integrated between the facility and the Hospice agency.

Interview with the Director of Nursing (DON) on October 29, 2021, at 9:50 AM, confirmed that hospice care was not integrated into the resident's comprehensive person-centered care plan to demonstrate coordination of services between the Hospice agency. The DON also confirmed that there was no physician order to begin hospice care.

28 Pa. Code 211.11 (a)(b)(c)(d) Resident care plan

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

Plan of Correction - To be completed: 12/14/2021

1. Resident 78 care plan was reviewed and revised to reflect Hospice services integration.

2. Current facility residents receiving Hospice services will have a care plan review for Hospice integration.

3. Staff Development Director will Inservice the IDT team on comprehensive person-centered care plan integration for Hospice Services.

4. DON and/or Designee will conduct random care plan audits for those receiving hospice services weekly for four weeks, then monthly for two months thereafter. The Quality Assurance Performance Improvement committee will review findings and make changes as needed.

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 interview it was determined that the facility failed to demonstrate the clinical necessity for use of an antipsychotic medication for one resident out of five sampled residents medication (Resident 66).

Findings included:

According to the FDA (federal drug administration) prescribing information, there is Increased Mortality in Elderly Patients with Dementia-Related Psychosis,
Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. SEROQUEL (Quetiapine) is not approved for the treatment of patients with dementia related Psychosis.

A review of the clinical record revealed that Resident 66 was admitted to the facility on August 26, 2021, with diagnoses, which included unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) without behavioral disturbance and major depression.

The resident had an initial physician order for the antipsychotic drug, Seroquel 12.5 mg by mouth once daily dated August 27, 2021.

Additionally, the hospital discharge medication sheet indicated that Resident 66 was receiving Seroquel 12.5 mg twice daily for anxiety.

Progress notes written by the nurse practitioner dated October 28, 2021, revealed that the resident had the presence of "psychotic symptoms", auditory, and visual hallucinations. However, at the time of the survey ending October 29, 2021, the facility failed to provide evidence of behavior monitoring for the months of August 2021 and September 2021.

An October 2021 behavior record was provided, which indicated that as of October 29, 2021, the resident had experienced an episode of hallucination on one occasion during the month of October 2021, on October 26, 2021.

Nursing progress notes dated October 26, 2021, indicated that she was pacing in the hallway and was carrying another resident's photograph around with her. When staff tried to remove the photograph from her she began kicking and biting. Later on that date the resident stated "I got mad at somebody here and I am sorry."

The nurse practitioner was interviewed on October 28, 2021, at 11:30 AM regarding the resident's need for Seroquel in the absence of an appropriate diagnosis or psychotic behaviors. The CRNP pointed out that her notes indicated that the resident had psychotic behaviors, but she was unable to direct the surveyors to the location of the supporting documented evidence indicating that the resident was displaying these behaviors. There was no behavior monitoring records, behavioral symptom tracking or progress notes indicating that the resident was displaying psychotic behavior.

There was no physician documentation of the clinical indicators supporting the resident's use of the antipsychotic drug.

Interview with the director of nursing (DON) on October 28, 2021, at 1:30 PM, confirmed that Resident 66 did not have an appropriate diagnosis to warrant the use of an antipsychotic medication.

28 Pa. Code 211.2(a) Physician services

28 Pa. Code 211.5(f)(g)(h) Clinical records

28 Pa. Code 211.9(k) Pharmacy services

Plan of Correction - To be completed: 12/14/2021

1. R 66 will be assessed by her attending physician to determine if the medication is clinically necessary to treat the resident. Behavior tracking will be initiated to monitor and track any behaviors.

2. Residents currently receiving antipsychotic medications will be reviewed to ensure behavior tracking is in place to monitor and track behaviors for the use of antipsychotic medication.

3. The Social Service Director will receive education on the process for monitoring resident behaviors for justification of use.

4. Social Service Director and/or designee will conduct random audits of residents receiving antipsychotic medication to validate behavior tracking is in place for justification of use for antipsychotic med. Audits will be completed weekly for four weeks then monthly for two months thereafter. The Quality Assurance Performance Improvement committee will review findings and make changes as needed.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on a review of clinical records and staff interviews it was determined that the facility failed to implement pharmacy procedures for disposal of controlled drugs for one discharged resident out of three sampled (Resident 115).

Findings included:

A review of the facility's policy entitled "Discarding and Destroying Medications" last reviewed by the facility May 2021, indicated that medications will be disposed of in accordance with federal, state and local regulations governing management of hazardous waste and controlled substance. The medication disposition record will contain the name and strength of the medication, quantity disposed, method of disposition and reason for the disposition.

A review of the clinical record revealed that Resident 11 was admitted to the facility on August 21, 2021, with diagnoses of End Stage Alzheimers. Resident 11 was receiving the Hospice benefit. The resident passed away at the facility on August 26, 2021.

A review of physician orders revealed an order, dated August 21, 2021, for Morphine Sulfate (Concentrate) 10 MG sublingually every 4 hours for pain and SOB.

A review of the document entitled Individual Resident Controlled Substance Record, dated August 26, 2021, of disposition of remaining doses revealed that the document failed to indicate the name of the medication that was to be destroyed. The amount of the medication received was 15 ML. The medication was administered to the resident three times, however, the record indicated that 15 ml was destroyed, the same amount as initially dispensed.

During an interview with the Nursing Home Administrator (NHA) on October 29, 2021, at 11:38 AM, the NHA acknowledged that the facility failed to implement its procedures for the Individual Resident Controlled Substance Record.

28 Pa. Code 211.9(j) Pharmacy services

Plan of Correction - To be completed: 12/14/2021

1. Resident 115 was discharged from the facility prior to survey.

2. A review of the controlled drug records for discharged residents over the past 30 days will be reviewed for medication destruction and name of medication is indicated on the record.

3. Staff Development Director will review/educate on the policy procedure for the Destruction of Controlled Substances with licensed staff.

4. DON and/or Designee will conduct random audits of the Controlled Substance records for discharged residents for accuracy weekly for four weeks then monthly for two months thereafter. The Quality Assurance Performance Improvement committee will review findings and make changes as needed.

483.25(l) REQUIREMENT Dialysis:

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on review of clinical records and select facility policy, observations, and staff interview it was determined that the facility failed to monitor a physician's ordered fluid restriction to deter fluid overload and consistently monitor weight changes surrounding dialysis treatments and notify the physician of the resident's significant weight gains for one resident receiving dialysis out of two sampled residents (Resident 13)

Findings included:

Review of a facility policy entitled "Fluid Restriction" with a policy review date of May 2021, indicated that nursing will record all fluid intake on the intakes worksheet and in the Electronic Medical Record.

Resident 13 was admitted to the facility on May 30, 2019, with diagnoses to have included end stage chronic kidney disease with dependence on hemodialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood), cerebral infarction [or known as a stroke], and dementia.

Review of Resident 13's care plan initiated on May 31, 2019, indicated that the resident was prescribed a 1500 milliliter/day to manage fluid overload with a goal to accept fluid restriction as ordered. Interventions planned was 1500 ml fluid restriction (breakdown from dietary breakfast 420 ml, lunch 240 ml, and dinner 240 ml and nursing would provide on 7AM-3pm 240 ml, 3pm-11 pm 240 ml, and 11 pm -7 am 120 ml) and to encourage foods/fluids to meet estimated nutritional needs.

The resident had a physician order dated December 23, 2020, at 8:34 PM, for dialysis three times per week at 7:00 AM on day shift, Tuesdays, Thursdays, and Saturdays. Resident 13 also had a physician order for a fluid restriction for 1500 cc per 24-hour with the breakdown as follows: breakfast 420 cc, lunch 240 cc, dinner 240 cc and nursing to give on 7AM to 3 pm shift 240 cc, 3 PM to 11 PM shift, and 11 PM to 7 AM 240 cc.

Review of Resident 13's clinical records, including Medication Administration Records, revealed no documented evidence that nursing was accurately monitoring the amount of fluids nursing staff was providing with medications and other free fluids.

Review of facility's policy entitled "Weighing of Residents" with a policy review date of May 2021, revealed that the facility must monitor the resident's weight to detect significant weight loss or gain in order to ensure that the resident maintains acceptable parameters of nutritional status. Resident's weights are obtained at least monthly and if the resident exhibits a weight change of 5 pounds more or less than the previous weight, the resident shall be re-weighed within 24 hours and documented in the resident's electronic health record. The RD will monitor the weights from the weight summary report and monthly weights reports.

Review of Resident 13's "Weight Record" revealed the resident's weight on September 3, 2021, at 11:32 AM, was 192 pounds (lbs.) and weight on October 6, 2021, at 10:47 AM, was 197.12 lbs, a 5.12-pound (lbs.) weight gain in a month.

Review of the facility's "Dialysis Communication Sheet" revealed that on September 7, 2021, Resident 13 weighed 199.54- lbs, a 7.54-pounds (lbs.) significant weight gain since the facility's last recorded weight on September 3, 2021.

Interview with the facility's registered dietitian (RD) on October 28, 2021, at 1:20 PM, indicated that she was able to look at total fluid intakes, but since the "Additional Fluids" task was removed from the electronic tracking system (electronic health record) that she was unable to see the fluids given by nursing to fully assess the resident's oral fluid intakes. The RD stated that the resident's post dialysis weights are recorded and reviewed monthly.

There was no documented evidence in Resident 13's clinical record of adherence to the physician ordered fluid restriction and no documented evidence that the facility was monitoring the resident's weight gains.

Interview with the director of nursing (DON) on October 29, 2021, at 9:45 AM, confirmed that the facility failed to accurately document fluid intakes for a resident ordered on a fluid restriction to assure that the resident's fluid intake was accurately assessed. The DON also verified that the facility failed to document and monitor significant weight changes as indicated in the facility's "Weighing of Resident" policy.

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

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

Plan of Correction - To be completed: 12/14/2021

1. Resident 13 fluid restriction was reviewed by the physician to reflect current fluids needs.

2. Current facility residents with ordered fluid restrictions will be reviewed by facility RD to verify any fluctuations/changes in weights. Resident physician to be updated if needed.

3. Policy and procedure for fluid restriction will be reviewed/revised as needed. Staff Development Director will conduct an in-service education for RD and licensed staff on the fluid restriction policy.

4. Registered Dietician and/or Designee will conduct audits of those residents requiring a fluid restriction weekly for four weeks then monthly for two months thereafter. The Quality Assurance Performance Improvement committee will review findings and make changes as needed.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 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 observation and clinical record review, it was determined the facility failed to provide oxygen therapy as prescribed by the physician for one of one resident sampled receiving oxygen (Resident 43).

Findings include:

A review of the clinical record of Resident 43 revealed a physician order dated August 1, 2021, for oxygen 2 liters per minute (l/pm) continuous via nasal cannula (pronged tubing that delivers oxygen to the nose), humidify and checks every shift for oxygenation.

Observation of the resident on October 28, 2021, at 2:16 PM, while in his room sitting in his wheelchair, revealed that the resident's oxygen tank was on empty. The resident stated there was no air coming through his nasal cannula.

Employee 4 (Licensed Practical Nurse) was immediately informed of the residents's empty oxygen tank.

Interview with the Director of Nursing on October 28, 2021, verified that physician orders for oxygen were not followed for this resident

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

Plan of Correction - To be completed: 12/14/2021

1. Resident 43 oxygen tank was replaced at the time of the survey.

2. DON and/or designee will conduct an initial audit of current facility residents utilizing oxygen to verify physician orders are being followed.

3. The facility policy for Oxygen Administration will be reviewed and revised. Changes to the policy will include licensed staff validation that oxygen is available qs via oxygen tank or concentrator. Staff Development Director will conduct education for Licensed Nurses related to this policy change.

4. DON and/or Designee will conduct random audits weekly for four weeks, then monthly for two months of current facility residents utilizing oxygen to verify physician orders are being followed. The Quality Assurance Performance Improvement committee will review findings and make changes as needed

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Observations:

Based on review of clinical records and transfer notices and staff interview it was determined the facility failed to provide sufficiently detailed written notices of facility-initiated transfers to the hospital to the resident and the residents' representative and failed to ensure that a notice of transfer to the hospital, identifying the reasons for the move was in writing and in an understandable language and manner for four out of four residents reviewed for hospitalizations (Residents 53, 103 and Resident 74).

Findings include:

A review of Resident 103's clinical record revealed that on September 13, 2021, at approximately 12:56 PM he was sent to the hospital emergency department due to a fall that occurred on September 12, 2021. Mobile X-ray had identified no injury, however on September 13, 2021, the resident's left leg was observed to be shorter than his right leg. Another Mobile X-ray was completed, which indicated a fracture (broken bone) of the left femur (large long bone in leg). The resident was admitted to the hospital for surgical repair and he returned to the faciltiy on September 16, 2021.

A review of the facility's Notice of Transfer on Discharge revealed he was being transferred for "left hip fracture." The written notice lacked a statement of the resident's appeal rights, information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request, the correct address for the Bureau of Hearings and Appeals, and the name of the State Long Term Care Ombudsman. It also failed to contain the name and address of the address for the Advocacy for Persons with Disabilities, if applicable.

Resident 74's clinical record revealed on August 22, 2021, the resident was transferred to the hospital for vomiting with a coffee ground like appearance and she returned to the facility on August 25, 2021.

A review of the facility's Notice of Transfer on Discharge revealed the written notice lacked a statement of the resident's appeal rights, information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request, the correct address for the Bureau of Hearings and Appeals, and the name of the State Long Term Care Ombudsman. It also failed to contain the name and address of the address for the Advocacy for Persons with Disabilities, if applicable.

Resident 53's clinical record review revealed that the resident was transferred to the hospital on February 5, 2021, for abnormal labs and returned to the facility on February 5, 2021. The resident was transferred to the hospital May 13, 2021, for lethargy and returned to the facility on May 27, 2021. The resident was transferred to the hospital on July 7, 2021, for abnormal labs/CHF and returned to the facility on July 11, 2021. The resident was transferred to the hospital on August 5, 2021, for shortness of breath and returned to the facility on August 9, 2021. The resident was transferred to the hospital on August 13, 2021, for shortness of breath and returned to the facility on August 18, 2021. The resident was transferred to the hospital on September 11, 2021, for altered mental and returned to the facility on September 13, 2021.

A review of the facility's Notice of Transfer or Discharge revealed that the written notices lacked a statement of the resident's appeal rights, information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request, the correct address for the Bureau of Hearings and Appeals, and the name of the State Long Term Care Ombudsman. It also failed to contain the name and address of the address for the Advocacy for Persons with Disabilities.

Resident 64's clinical record revealed that on August 22, 2021, the resident was transferred to the hospital August 22, 2021, for high temp/low oxygen levels and returned to the facility on August 24, 2021.

A review of the facility's Notice of Transfer on Discharge revealed the written notice lacked a statement of the resident's appeal rights, information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request, the correct address for the Bureau of Hearings and Appeals, and the name of the State Long Term Care Ombudsman. It also failed to contain the name and address of the address for the Advocacy for Persons with Disabilities, if applicable.

During an interview with the Director of Nursing (DON), on October 28, 2021, at approximately 11:00 a.m. confirmed they were unable to provide documented evidence of the provision of written notices of discharge that included the regulatory required information and notification of transfer in a language and manner understood by the resident and/or resident representative.

28 Pa. Code 201.29 (f)(g)(j)Resident Rights

28 Pa. Code 201.14(a) Responsibility of Licensee

Plan of Correction - To be completed: 12/14/2021

1.Residents 103, 74, 53 and 64 cannot be retroactively corrected. The facilities form has been updated to contain the necessary information.

2.Social Service Director and/or Designee will verify that residents transferred out are receiving the proper notice form.

3.The facility has updated the form to provide the necessary information for residents. The Social Service Director and Admissions Coordinator have been re-educated on the form to use for transfers on discharge.

4.Social Service Director and/or Designee will conduct random audits weekly for four weeks and then monthly for two months thereafter to verify that residents transferred out are receiving the proper notice form. The Quality Assurance Performance Improvement committee will review findings and make changes as needed.

§ 201.19 LICENSURE Personnel policies and procedures.:

Personnel records shall be kept current and available for each employe and contain sufficient information to support placement in the position to which assigned.

Observations:

Based on a review of five personnel records and staff interview, it was determined that the facility failed to maintain complete employee personnel records, which included current job descriptions for one of five newly hired employees (Employee 5)

Findings include:

The personnel record of Employee 5, a housekeeper, hired October 7, 2021, failed to include a current signed job description.

An interview with Employee 6, Human Resource Director, on October 29, 2021 at approximately 12:00 PM confirmed that signed job descriptions are not included in employee personnel records.

Plan of Correction - To be completed: 12/14/2021

1. Employee 5 has received a job description and has been signed for their file.

2. Human Resource Director will conduct an initial audit of employees to verify they have a job description on file.

3. The Nursing Home Administrator or Designee will re-educate the Interdisciplinary team to ensuring they have job descriptions on file for their employees.

4. Human Resource Director will conduct random audits weekly for four weeks and then monthly for two months thereafter of new hires to verify they have a job description on file. The Quality Assurance Performance Improvement committee will review findings and make changes as needed.

§ 201.22(j) LICENSURE Prevention, control and surveillance of TB.:

(j) New employes shall have the 2-step intradermal skin test before beginning employment unless there is documentation of a previous positive skin reaction. Test results shall be made available prior to assumption of job responsibilities. CDC guidelines shall be followed with regard to repeat periodic testing of all employes.

Observations:

Based on review of personnel records of newly hired employees since the last survey and facility policy and interviews with staff, it was determined that the facility failed to ensure that one of five newly hired employees (Employee 5) received the 2-step intradermal skin test (PPD) before beginning employment.

Findings include:

Review of the facility's policy dated as reviewed May 2021 entitled "Tuberculosis Skin Testing Procedure for Employees," revealed new employees shall have a 2-step intradermal skin test before beginning employment.

Review of personnel records of the last five newly hired employees revealed that Employee 5 housekeeping was hired on October 7, 2021. No documentation was found that the employee received a 2-step intradermal skin test prior to employment at the facility .

Interview with the Employee 6 Human Resource Director on October 29, 2021, at approximately 12:00 PM confirmed the employee did not have the required 2-step skin test prior to employment.

Plan of Correction - To be completed: 12/14/2021

1. Employee 5 has proper tuberculosis testing on file.

2. Human Resource Director will conduct an initial audit of employees to verify they have tuberculosis testing on file.

3. The Nursing Home Administrator or Designee will re-educate the Interdisciplinary team to ensuring they have tuberculosis testing on file for their employees.

4. Human Resource Director will conduct random audits weekly for four weeks and then monthly for two months thereafter of new hires to verify they have tuberculosis testing on file. The Quality Assurance Performance Improvement committee will review findings and make changes as needed.

§ 211.9(g) LICENSURE Pharmacy services.:

(g) If over-the-counter drugs are maintained in the facility, they shall bear the original label and shall have the name of the resident on the label of the container. The charge nurse may record a resident's name on the nonprescription label. The use of nonprescription drugs shall be limited by quantity and category according to the needs of the resident. Facility policies shall indicate the procedure for handling and billing of nonprescription drugs.

Observations:

Based on observation, staff interview and review of a facility exception request it was determined the facility failed to compile a current listing of all residents utilizing house stock medications including two residents out of 4 residents observed during the medication administration (Resident 61 and 88)

Findings include:

Observation of the medication administration to Resident 61 on October 27, 2021, at 8:05 AM revealed that Resident 61 had physician orders for Acetaminophen 500 mg, Enteric Coated Aspirin 81 mg, and Multivitamin with minerals, Employee 7 a licensed practical nurse (LPN) administered these stock medications to this resident.

Observation of the medication administration to Resident 88 on October 27, 2021, at 8:15 AM revealed that Resident 88 had physician orders for Acetaminophen 500 mg, Employee 4 a licensed practical nurse (LPN) administered this stock medication to this resident.

Observation of the house stock bottles for the above medications revealed that Resident's 61 and 88's names did not appear on the labels. Employee 7 (LPN) provided a stock medication list which was contained on the medication cart in a binder. However, this listing had not been updated since July 28, 2020 and did not contain current resident names and listing of stock medications for all residents currently residing in the facility receiving house stock medications.

The stock medication list contained on the medication cart had names of multiple residents who no longer resided in the facility.

A review of the state exception granted to the facility by the department dated June 27, 2014 indicated the facility was granted and exception and the faciltiy implemented the use of a list which details the names of all residents who are prescribed over the counter medications.

The facility failed to maintain current lists of stock medications for resident use at the time of this survey ending October 29, 2021.

Plan of Correction - To be completed: 12/14/2021

1. The over-the-counter lists were placed on the medication carts at the time of the survey.

2. Verification for over-the-counter lists located on each med cart was completed.

3. Over the counter medication lists will be obtained monthly through facility pharmacy and placed on medication carts.

4. DON and/or designee will audit monthly that the over-the-counter lists are present on medication carts for three months. The Quality Assurance Performance Improvement committee will review findings and make changes as needed.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement