Nursing Investigation Results -

Pennsylvania Department of Health
HARMONY PHYSICAL REHABILITATION
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HARMONY PHYSICAL REHABILITATION
Inspection Results For:

There are  14 surveys for this facility. Please select a date to view the survey results.

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HARMONY PHYSICAL REHABILITATION - 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 Survey completed on December 12, 2019, it was determined that Harmony Physical Rehabilitation 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(j)(1)-(4) REQUIREMENT Grievances:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:


Based on a review of facility policy, resident council minutes and staff interview, it was determined that the facility failed to make certain that grievances from Resident Council were addressed for five of eight months (May, June, July, September and November 2019)

Findings include:

The facility policy " Grievances, Resident" dated 3/19/19, indicated that the facility will do its best to respond to the resident's issue/concern within 24 hours after a thorough investigation is conducted. The resident (or resident representative) will receive notification of the outcome. A resident ( or resdient representative) with a problem should express it as soon as possible after it occurs.

During a review of Resident Council Minutes dated 5/30/19, 6/28/19, 7/29/19, 9/30/19 and 11/22/19, there were four concerns that calls bells were too long, a room needed cleaned and food orders aren't correct.

Review of the Resident Council Minutes dated 5/30/19, 6/28/19, 7/29/19, 9/30/19 and 11/22/19, revealed that the resident council concerns were not addressed.

During an interview on 12/12/19, at 1:00 p.m.. with Nursing Home Administrator Employee confirmed that there was no documentation that the resident concerns had been investigated and that the resident council concerns were not included in the facility grievance process.

28. Pa Code: 201.18(e)(4) Management.

28. Pa Code: 201.29(i) Resident rights



 Plan of Correction - To be completed: 01/21/2020

1. Resident council minutes will now include follow up documentation on identified resident council concerns. The resident council concerns will also be documented on a facility grievance form.

2. Current patients have the potential to be affected. The facility will hold a resident council meeting to identify any resident council concerns. The resident council minutes which had concerns with call bell response time, resident room needing to be cleaned and a meal order not correct as identified during survey will be reviewed with the current patients to determine if these areas remain a concern with the new short term patients. Any new or old reported concerns will be documented on a grievance form and follow up will be documented on the resident council minutes.

3. The nursing home administrator will educate the department managers on the 585 regulation and the facility's grievance policy and documentation of follow up for each grievance.

4. The Administrator will review resident council minutes monthly to validate grievances along with corresponding follow up documentation was completed for each concern identified in resident council. This audit will be completed monthly for three months and then randomly thereafter. Results of this audit will be communicated at the Quality Assessment and Assurance Committee meetings

483.25(l) REQUIREMENT Dialysis: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(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 policy, clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for dialysis treatments for one of one residents. (Resident R86).

Findings include:

Review of the facility policy "Resident Who Require Renal Dialysis" last reviewed 3/19/19, indicated that communication between facilities will be handled if specifically required.

Review of the clinical record revealed that Resident R86 was admitted to the facility on 12/5/19, with diagnoses that included acute kidney failure (a malfunction of the kidneys making them unable to filter waste from the blood), dependence on renal dialysis, high blood pressure and diabetes.

Review of the physician orders dated 12/19, indicated that Resident R86 is to start dialysis on 12/6/19, and will receive treatment every Monday, Wednesday and Friday.

Review of the clinical record did not include a completed dialysis communication form for three of the three dialysis visits (12/6, 12/9 and 12/11).

During an interview on 12/12/19, 2:02 p.m. the Director of Nursing confirmed that the facility failed to make certain consistent dialysis communication was maintained for Resident R86.

28 Pa. Code: Clinical records.

28 Pa. Code: Clinical records.

28 Pa. Code: Management.

28 Pa. Code: Management.

28 Pa. Code: Resident care policies.

28 Pa. Code: Nursing services.



 Plan of Correction - To be completed: 01/21/2020

1. R86 has been discharged to from our facility.

2. Current dialysis patients have the potential to be affected. The facility will complete an audit on current patients in house of 1/6/20 to identify any dialysis patients. Identified patients will have a chart audit completed to determine if the dialysis communication form is completed according to the patient's specific dialysis treatment schedule. Any residents identified without the communication tool will have immediate correct action taken.

3. The Director of Nursing will educate the licensed staff on federal regulation 0698 and the facility policy on "Residents Who Require Renal Dialysis". Staff identified not implementing the facility policy will receive progressive discipline.

4. The Director of Nursing and/or designee will audit dialysis patients once a week for three months to determine if the communication between facilities is being completed per policy. The audit will be completed monthly after three months. Results of this audit will be communicated at the Quality Assessment and Assurance Committee meetings

201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:

Based on review of facility infection control policies and procedures, infection control surveillance, and staff interview, it was determined that the facility failed to comply with the following requirements of MCARE Act 403(a)(1).

Findings include:

MCARE Act, Section 403(a)(1), 40 P.S. 1303.403(a)(1) - Infection Control Plan, states:

(a) Development and compliance - Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include:
(1) A multidisciplinary committee including representatives from each of the following, if applicable to the specific health care facility:
(i) Medical staff that could include the chief medical officer or the nursing home medical director.
(ii) Administration representatives that could include the chief executive officer, the chief financial officer or the nursing home administrator.
(iii) Laboratory personnel.
(iv) Nursing staff that could include a director of nursing or a nursing supervisor.
(v) Pharmacy staff that could include the chief of pharmacy.
(vi) Physical plant personnel.
(vii) A patient safety officer.
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility or ambulatory surgical facility.

A review of the facility infection control surveillance (tracking of all infections within the facility in an effort to identify trends or to prevent further infections from developing) and Infection Control Committee minutes for the Quarterly meetings for 4/18/19, 7/18/19 and 10/31/19, revealed no evidence to indicate that the facility had the representation of the Infection Control Team (Infection Specialist) for the Quarterly interdisciplinary Infection Control Committee meetings, a community member or laboratory personnel as a part of the interdisciplinary Infection Control Committee.

MCARE Act, Section 403(a)(1), 40 P.S. 1303.405(a) - Patient Safety Authority Jurisdiction, states:

(a) HEALTH CARE FACILITY REPORTS TO AUTHORITY. - The occurrence of a health care-associated infection in a health care facility shall be deemed a serious event. Written notification to the resident of the serious event should be documented.

A review of the facility Pennsylvania Patient Safety Reporting System Reports (PAPSRS) and facility documentation did not include written notification to the resident of the health care-associated infection.

During an interview on 12/12/19, at 10:36 a.m. the Infection Specialist Employee E1 confirmed that the he/she did not attend the Infection Control Committee meetings and could not provide information that written notification to the residents was made of health care-associated infections as required.



 Plan of Correction - To be completed: 01/21/2020

1. The facility now has an Infection Specialist, community member and a lab personnel attending the Infection Control Committee meetings. The facility is now providing written documentation to the residents with health care-associated infections.

2. Current patients have the potential to be affected. The facility will review current patients in house on January 6th to determine if any patients require the written notification of a health care-associated infection. Identified residents will be provided the written documentation immediately.

3. The administrator will review the regulation 0400 with the Director of Nursing and the Infection Specialist. Staff identified not implementing the regulation will have progressive discipline.

4. The Director of Nursing will audit the health care-associated infections to validate written documentation was provided to the affected patients. This audit will be completed weekly for three months and then monthly thereafter. The administrator will audit attendance of the infection specialist for the infection control committee meetings. Results of these audits will be communicated at the Quality Assessment and Assurance Committee meetings

205.10(c) LICENSURE Doors.:State only Deficiency.
(c) A door to a toilet room which swings into the toilet area shall be equipped with special hardware which permits the door to be opened from the outside, and swing out, in case of emergency.
Observations:

Based on observation and staff interview, it was determined that the facility failed to ensure that resident restroom doors could be opened from the outside and swing outward in the event of an emergency on two of two Nursing Units (first and second floor nursing units).

Findings include:

Observation on 12/11/19, at 11:31 a.m. of the first nursing unit and at 11:44 a.m. of the second floor revealed two resident restrooms, on each floor, located in the hallway area. The restroom doors did not have the ability to swing outward in the event of an emergency.

During an interview on 12/11/19, at 2:55 p.m. the Nursing Home Administrator, confirmed the restroom doors do not have the ability to swing outward in the event of an emergency.





 Plan of Correction - To be completed: 01/21/2020

1. The identified restroom doors on the first and second floors now have the ability to permit the door to be opened from the outside.

2. Current public restrooms have the potential to be affected. The facility will audit current public restrooms to determine if any other doors are affected. Identified doors will have corrective action taken.

3. The administrator will educate the maintenance department on regulation 0925.

4. The administrator will complete a monthly audit on public restrooms to validate doors can be opened from the outside. The audit will be completed for three months and then randomly thereafter. Results of this audit will be communicated at the Quality Assessment and Assurance Committee meetings

205.26(e) LICENSURE Laundry.:State only Deficiency.
(e) Equipment shall be made available and accessible for residents desiring to do their personal laundry.
Observations:

Based on observation and staff interview, it was determined that the facility failed to make laundry equipment available to residents for personal use.

Findings include:

During an observation of the laundry area on 12/11/19, at 2:30 p.m., revealed laundry equipment that was not available to residents.

During an interview on 12/11/19, at 2:55 p.m., the Nursing Home Administrator confirmed that washers and dryers were not available to residents for personal use.



 Plan of Correction - To be completed: 01/21/2020

1. The facility will make the laundry equipment accessible for residents for personal use. The personal laundry room will be located in the therapy gym.

2. Current patients have the potential to be affected.

3. The nursing home administrator will educate the maintenance department on the P 1100 regulation.

4. The administrator will audit the laundry equipment on a monthly basis to validate its accessibility to current patients. Results of this audit will be communicated at the Quality Assessment and Assurance Committee meetings


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