Nursing Investigation Results -

Pennsylvania Department of Health
TULIP SPECIAL CARE, LLC
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

TULIP SPECIAL CARE, LLC
Inspection Results For:
There are 15 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.


TULIP SPECIAL CARE, LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey, and an Abbreivated Survey in response to a complaint completed on February 5, 2020, it was determined that Tulip Special Care, LLC was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the Health portion of the survey process.

Plan of Correction:

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:

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(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

Observations:

Based on review of facility policie and interviews with staff and residents, it was determined that the facility did not properly inform residents of their right to organize resident groups, and did not provide the opportunity for residents to organize and participate in resident groups.

Findings include:

Interview with the Nursing Home Administrator and Assistant Nursing Home Administrator on February 4, 2020, at approximately 2:15 p.m. revealed that past Resident Council Minutes were not available. The Assistant Nursing Home Administrator, Employee E8, stated that Resident R45 was alert and oriented and was the designated Resident Council President. Employee E8 also stated that they have had discussions with Resident R45 regarding any concerns, requests, and/or questions he had, but he did not meet, nor was he given the opportunity to meet, with other residents to discuss and/or determine concerns.

During the same interview on February 4, 2020, at approximately 2:15 p.m., the Nursing Home Administrator stated that "due to the type of residents" the facility serves, it would be difficult to accomplish successfully. During the same interview it was also confirmed that the facility had no written policies or procedures regarding the management of resident and/or family groups, if they were established in the facility

Interviews with Residents R45, R24, R40, and R43 revealed that the opportunity to meet with other residents and participate as a group to discuss concerns and likes and dislikes was not presented to them.

During an interview with the Nursing Home Administrator on February 5, 2010, at approximately 3:30 p.m., it was confirmed that the facility did not inform the residents of their right to organize a group, or provide the opportunity to participate in a resident group.

The facility failed to inform the residents of the right to organize a group and did not provide the opportunity to participate in a resident group.

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

28 Pa. Code 201.29(j) Resident rights

Plan of Correction - To be completed: 04/05/2020

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

Informal Resident Council meetings have taken place at Tulip Special Care in the past.

The first formal Resident Council meeting took place on February 5, 2019.

The policy and procedure for Resident Council has been revised. The policy allows for Patients/Residents to participate as a group to discuss concerns, likes, and dislikes.

The revised policy and procedures will be reviewed with the patients/residents at a the next Resident Council meeting. It was also delivered to each patient/resident's room in paper form by social services.

An in-service for all staff has taken place on the revised policy for Resident Council meetings.

The Social Services Director has been invited by the Resident Council to attend meetings and record minutes.

The action items contained in the minutes will be brought to the morning meeting and or the monthly QAPI meeting for review/resolution. If necessary, grievance forms will be completed.

The Social Services Director will audit the Resident Council minutes and schedule to ensure compliance.

To be monitored by the Assistant Nursing Home Administrator or designee.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Observations:

Based on review of test tray results and resident and staff interviews, it was determined that the facility failed to serve foods at palatable and proper temperatures.

Findings include:

Review of facility policy "Test tray" dated, April 1, 2018 revealed that "Food temperature will be obtained prior to meal service and recorded on the Test tray Audit form. Further review of the policy revealed that the acceptable temperature for entree, starch, vegetables, hot cereal and hot beverages as 135-degree Fahrenheit(F) or above. The acceptable temperature for cold beverages, salad and dessert as 40-50-degree F

Interview with Resident R36 on February 3, 2020 at approximately 11:26 a.m., the resident stated that the hot food was sometimes not served hot and cold food was sometimes not served cold.

Interview with Resident R26 on February 3, 2020 at approximately 12:54 p.m., the resident stated that the hot food was mostly not served hot.

Review of the facility food temperature audit form entitled, "Patient tray Temperature Assessment" revealed,

On January 2, 2020 at breakfast, the omelet and sausage were at 108- degrees Fahrenheit (F) and 107-degree F respectively. The toast was served at 78.5-degree F. In addition, the orange juice was served at 53-degree Fahrenheit.

On January 13, 2020 at breakfast, the eggs and sausage were at 114- degrees Fahrenheit (F) and 110-degree F respectively. The coffee was served at 124-degree F.

On January 13, 2020, at lunch, the soup was served at 110- degrees. The sandwich was served at 99.5-degree F. Cooked carrots at 97.5-degree F.

On January 23, 2020 at breakfast, the eggs and sausage were at 111- degrees Fahrenheit (F) and 109-degree F respectively.

On February 3, 2020 at breakfast, the eggs and sausage were at 115- degrees Fahrenheit (F) and 107.5-degree F respectively. The coffee was served at 120.5-degree F. The oatmeal was served at 127-degree F.

Observation of the lunch meal on February 4, 2020 at approximately 12:57 p.m. on the nursing unit revealed the Ravioli was served at 133.7-degree F.

Interview with Registered Dietician, Employee E5, on February 4, 2020 at approximately 1:00 p.m. confirmed that the temperature was not an acceptable delivery temperature.

The facility failed to serve foods at palatable and proper temperatures.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/01/19, 04/06/19

28 Pa. Code 201.18(b)(3) Management
Previously cited 09/05/19, 04/06/19

28 Pa. Code 211.6(c) Dietary services

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints:

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

§483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Observations:

Based on observation, review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to provide documentation of comprehensive assessment and ongoing re-evaluation for the continued need for physical restraints, for two of three residents reviewed with restraints (Residents R98 and R8).

Findings include:

Review of facility policy, "Restraints," dated April 1, 2018, defined that a physical restraint is any device or equipment attached to a resident's body, that the individual cannot remove easily, which restricts normal access to one's body, and includes, but is not limited to, hand mitts.

The policy added that the decision to use such devices would be comprehensively assessed by the interdisciplinary team which would consider the resident's physical and cognitive status, the risks and benefits of the use of a device, and based on this assessment, whether the use of a restraining, non-restraining, or no device is necessary.

The policy additionally revealed that staff would conduct an initial assessment to determine the need for any device and what is the appropriate and least restrictive device; that the potential use of the device would be discussed with the resident or resident's family specifying, "Documentation of name must be done;" and that the resident/family would sign a, "restraint consent."

Review of the clinical record for Resident R98 revealed the resident was admitted to the facility on January 28, 2020, with diagnoses including, but not limited to, respiratory failure (medical condition where a person cannot breathe on one's own) requiring a ventilator (breathing machine) via tracheostomy (tube inserted through the neck to assist breathing); kidney failure requiring hemodialysis (process of removing waste products and excess water from the body) through a left chest wall permacath (tube inserted through the chest and thread into the heart); and tube feeding (tube inserted through the skin into the stomach/digestive tract to administer liquid nutrition, fluids and medications).

Review of the nursing "Admit/Readmit Screener" assessment dated January 28, 2020, at 5:40 p.m. revealed Resident R98 had bilateral (both sides) hand mitts in place for safety.

Review of a nursing admission summary progress note, dated January 28, 2020, at 5:45 p.m. revealed Resident R98 was awake and oriented times 1-2 (varying accurate knowledge of person and place), could nod head appropiately to simple yes/no questions, and that bilateral hand mitts were in place for safety.

Review of a physician's order dated January 28, 2020, instructed staff to apply bilateral hand mitts to Resident R98 for safety.

Further review of the clinical record revealed no documentation that Resident R98 was assessed by the interdisciplinary team upon admission on January 28, 2020, to determine the need for the hand mitts other than for "safety"; no documentation of what the resident's behaviors or medical conditions were to warrant the use of the hand mitts; no documentation that the resident's family was notified of the use of the hand mitts; and no documentation that the family signed the facility's "restraint consent."

Interview with the Director of Nursing on February 5, 2020, at approximately 9:45 a.m. confirmed there was no documented evidence of interdisciplinary team assessment for the use of bilateral hand mitts and no documented evidence that the resident's family was notified of the use of bilateral hand mitts for Resident R98.

Review of clinical record for Resident R8 revealed that the resident was admitted to the facility on August 12, 2019 with diagnosis including but not limited to anoxic brain damage(a type of brain injury that occurs when the brain is deprived of oxygen) and non- traumatic intracranial hemorrhage(bleeding inside the brain) and depended on ventilator(machine used to assist with breathing).

Observation of the Resident R8 on February 5, 2020 at approximately 10:00 a.m. revealed that she was wearing a hand mitt to her left hand.

Review of quarterly Minimum Data Set (MDS-Periodic assessment of resident needs) dated November 15, 2019 revealed that the resident was using limb restraint on a daily basis both in and out of bed.

Review of physician's order for Resident R8 dated January 31, 2020 revealed an order to apply hand mitt to left hand.

Review of care plan for Resident R8 dated October 3, 2019 revealed that the resident used physical restraint (left hand mitt). Further review of the care plan revealed a care plan intervention which indicated, "every 30 days or sooner if necessary, the interdisciplinary team shall review and reevaluate the use of all restraints ordered by the physician."

Review of clinical record for Resident R8 revealed no documented evidence that staff reevaluated or reassessed the appropriateness of Resident R8's hand mitt every 30 days.

Interview with Employee E3, Registered Nurse, on February 5, 2020 confirmed that there was no evidence in the clinical record that the staff completed an assessment of Resident R8's hand mitt.

The facility failed to ensure that Residents R98 and R8 were assessed, and that the assessments were documented, for the initiation of and ongoing use of physical restraints.

28 Pa. Code 211.5(f) Clinical records
Previously cited 10/01/19, 04/06/19

28 Pa. Code 211.8(e)(f) Use of restraints

28 Pa. Code 211.10(d) Resident care policies
Previously cited 10/01/19, 04/06/19

28 Pa. Code 211.12(c) Nursing services
Previously cited 04/06/19

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 10/01/19, 09/05/19, 04/06/19

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 09/05/19, 04/06/19

Plan of Correction - To be completed: 04/05/2020

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

Residents R98 and R8 were re-assessed for the initiation of ongoing use of physical restraints (Bilateral hand mittens).

The policy and procedure "Restraints" dated April 1, 2018 has been updated to reflect compliance with F0604 and to capture the facilities actual operation as it pertains to restraints.

All staff have been in-serviced on the revised "Restraint" policy.

An audit of all records pertaining to Patients/Residents on restraints will be completed by the DON or designee weekly X 4 weeks.

The results of such audits will be brought to the QAPI Committee to determine the need for further audits.

Their procedure will be overseen by the Director of Nursing or designee.

483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident:

§483.24(c) Activities.
§483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.

Observations:

Based on observations, review of facility documentation and staff interviews, it was determined that the facility failed to provide an ongoing program of activities designed to meet the interests and physical, mental, and psychosocial well-being of three of three residents reviewed. (Resident 14, Resident 16, Resident 46)

Findings include:

Review of the policy "Activity/Recreation Programs," dated/ adopted April 1, 2018, stated the activity/recreational programs "shall be varied and include, but not be limited to: small, large, and individual programs are designed to meet the residents' needs and choice and include at least: in-room activities, religious/spiritual programs, ...social activities, community activities, and monthly resident council meetings; all programs reflect the cultural and religious interest of the residents; programs are offered on weekends, holidays, and evenings (at lest 2), and are scheduled at hours which are convenient to the residents; adequate supplies, equipment and community resources shall be available to meet the needs of residents with hearing and visual impairments and or language barriers."

Review of the activities calendars for November, December, 2019 revealed that for each date Monday through Friday, only one activity was listed for each day with no time, no location consisting of pokeno, craft (not specific), cards (not specific), bingo, game (not specific). There were no activities scheduled for Saturdays, Sundays, or evenings.

The November 2019 calendar had "off" listed for November 28 and 29, 2019 - Thanksgiving holidays; and the December 2019 calendar had "off" for December 13, 24, and 25, 2019 - Christmas holiday. There were no religious services listed. The January, 2020 calendar had the same activities listed, one per day - but did note "please join me in the Dining room for Activities daily at 2 p.m."

Review of Resident R14's Admission MDS dated November 19, 2019 identified the resident with a BIMS (Brief Interview of Mental Status) score of 14, which indicated that the resident was cognitive intact. Further review of the MDS under section title Preference for Customary and Activities revealed that it was very important for the resident to keep up with the news, and to have books, newspaper and magazines.

Review of Resident R14's November, 2019, December 2019 and January 2020 activity participation calendars indicated "R.V." on November 20, 21, 22, 25, 27. Review of December 2019 activity calendar revealed that the resident was offered room visits on December 2, 3, 4, 5, 9, 12, 16, 17, 18, 20, 23, 26, 27, 30. Review of January 2020 activity calendar noted that the resident had room visits on January 2, 6, 7, 9, 13, 14, 15, 16, 27. Review of activity notes revealed no documentated evidence of the resident response to the room visits and/or activities provided to meet the needs of the resident.

Review of Resident R16's Admission Minimum Data Set (MDS- resident assessment of care needs) dated December 10, 2019 identified the resident with long and short term memory impairment. Further review of the MDS under section title Preference for Customary and Activities revealed that it was very important for the resident to listen to music, keep up with the news, to do activities with groups of people, to participate in religious activities and in favorite activities.

Review of Resident R16's December 2019 and January 2020 activity participation calendars indicated that the resident activity consisted of "R.V." (room visits) on December 5, 9. 12, 17, 19, 23, 26 and 30. Review of January 2020 activity calendar noted that the resident had room visits on January 2, 3, 6, 8, 9, 13, 27, 28, 29. Review of activity notes revealed no documentated evidence of the resident response to the room visits and/or activities provided to meet the needs of the resident.

Review of Resident R46's Admission Minimum Data Set (MDS- resident assessment of care needs) dated October 11, 2019 identified the resident with a BIMS (Brief Interview of Mental Status) score of 14, which indicated that the resident was cognitive intact. Further review of the MDS under section title Preference for Customary and Activities revealed that it was very important for the resident to listen to music, keep up with the news, to do activities with groups of people, to participate in religious activities.

Review of Resident 46 's November, 2019, December 2019 and January 2020 activity participation calendars indicated "R.V." on November 22, 25, 26, and 27. Review of December 2019 activity calendar revealed that the resident was offered room visits on December 2, 3, 4, 5, 9, 10, 11, 12, 16, 17, 18, 19, 20. Review of January 2020 activity calendar noted that the resident had room visits on January 2, 3, 6, 7,8, 9, 10, 14, 15, 16. Review of activity notes revealed no documentated evidence of the resident response to the room visits and/or activities provided to meet the needs of the resident.

During an interview with the Nursing Home Administrator on February 4, 2020, at approximately 2:15 p.m., it was confirmed that the facility activities did not reflect the interests and needs of the residents.

The facility failed to provide an ongoing program of activities designed to meet the interests and physical, mental, and psychosocial well-being Resident

Refer to F680

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

28 Pa. Code 201.29(j) Resident rights
Previously cited 04/06/19

Plan of Correction - To be completed: 04/05/2020

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

The facilities policy and procedure entitled "Activity/Recreation Programs" dated April 1, 2018 has been revised to reflect activities designed to meet the interests and physical, mental and psychosocial well-being of the Patients/Residents.

An in-service took place with all staff on the revised policy and procedure.

The Assistant Administration or designee will audit the care plans, activity calendar, participation logs and MDS to ensure Patients/Residents needs are being met.

The audit will take place weekly X 4 weeks.

The results of such Audits will be brought to the monthly QAPI meeting for review and resolution.

To be monitored by the Assistant Nursing Home Administrator or designee.

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

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

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

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

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

Observations:

Based on review of the clinical record, facility policy and staff interviews, it was determined that the facility failed to address a significant weight loss and failed to consistently and accurately assess the nutritional status of one of 20 residents reviewed. (Resident R8).

Findings include:

Review of facility policy "Weights" dated April 01, 2018 revealed that "residents are routinely weighed at the following times:
Within 24 hours of admission or readmission to the facility.
Within 48 hours after admission or readmission.
Weekly X 4 weeks post admission.
Monthly thereafter unless specified otherwise by the physician".

Licensed nurse will request a re-weight within 24 hours if the recorded weight reflects a weight loss or gain equal to or greater than 5%. Notify physician, RNAC (Registered Nurse Assessment Coordinator) and Registered Dietician within 24 hours, if the re-weight verifies a significant weight change for the resident."

Review of clinical record for Resident R8 revealed that the resident was admitted to the facility on August 12, 2019.
Review of weight history for Resident R8 revealed that on August 13, 2019, the resident weighed 116.2 lbs. which was documented as the hospital weight. There was no evidence in the clinical record that the facility obtained an admission weight for Resident R8.

Further review of Resident R8's weight history revealed no evidence that the facility obtained post admission weekly weights for Resident R8.

Interview with Registered Dietician on February 5, 2020 at approximately 10:30 a.m. confirmed that the facility did not obtain an admission weight, weekly weights for four weeks and September 2019 monthly weight for Resident R8.

Review of clinical record revealed that Resident R8 weighed 103.2 pounds on October 14, 2019 which was -11.19 % loss from resident's last documented weight from August 13, 2019.

Review of clinical record for Resident R8 revealed no evidence that a reweight was performed and/or the resident'ss attending physician and the Registered Dietician was notified of the significant weight loss.

Interview with Registered Dietician on February 5, 2020 at approximately 10:30 a.m. confirmed that there was no evidence in the clinical record that the significant weight loss for Resident R8 on October 14, 2019 was addressed.

The facility failed to address a significant weight loss and failed to consistently and accurately assess the nutritional status for Resident R8.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/01/19, 04/06/19

28 Pa. Code 201.18(e)(1) Management
Previously cited 04/06/19

28 Pa. Code 211.6(d) Dietary services

483.25(h) REQUIREMENT Parenteral/IV Fluids:

§ 483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.

Observations:

Based on observation, review of clinical records and interviews with staff, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice related to intravenous (IV-tube inserted into a vein) lines for one of 20 residents reviewed (Resident R46).

Findings include:

Review of Resident R46's clinical record revealed the resident was admitted to the facility on January 14, 2020 with diagnoses including, end stage renal disease (when the gradual loss of kidney function reaches an advanced state), septicemia (bacterial infection in the bloodstream) and cerebrovascular accident (the sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired).

Review of Resident R46's physician's orders revealed an order to measure external catheter length and circumference of arm cm (centimeters) above IV (intravenous) insertion site weekly from the day of resident arrival.

Further review of Resident R46's clinical record revealed no documented evidence of the resident's upper extremity ' s arm circumference or the resident 's external PICC (peripherally inserted central catheter) line at the insertion site was measured.

Interview on February 4, 2020 at 10:59 a.m. with the licensed nursing staff Employee E3, confirmed there were no measurements of the external catheter length and circumference of the arm above the IV insertion site documented in the resident 's clinical record.

The facility failed to measure Resident R46's upper extremity's arm circumference and the resident's external PICC line at the insertion site.

CFR(s): 483.25(h) Parenteral/IV Fluids
Previously cited 04/06/19

28 Pa. Code 211.10(c) Resident care policies
Previously cited 09/05/19, 04/06/19

28 Pa. Code 211.12(c) Nursing services
Previously cited 04/06/19

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 10/01/19, 09/05/19, 04/06/19

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 10/01/19, 04/06/19

Plan of Correction - To be completed: 04/05/2020

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

It is the goal to ensure facility staff are properly trained to assess and monitor IV therapy.

Nursing staff have been educated on how to assess and monitor IV therapy needs of the Patients/Residents. Such education also includes measuring upper extremity arm circumference and Patient/Residents external PICC line at insertion site.

Patients/Residents with physician ordered IV's including PICC lines will be audited weekly x 4 weeks. Such audits will be performed by the Director of Nursing or designee.

Any discrepancies will have immediate corrective action and will be reviewed at the monthly QAPI for review/recommendation. Such recommendation will include the need for further audits.

To be monitored by DON or Designee.

§ 201.14(a) LICENSURE Responsibility of licensee.:

(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 staff interviews, review of facility policy and infection control committee attendance records, it was determined that the facility failed to comply with the requirements of Act 52 of 2007: Medical Care Availability and Reduction of Error (MCARE) Act.

Findings include:

Review of Act 52 of 2007: Medical Care Availability and Reduction of Error (MCARE) Act. Section 1303.403. Infection Control Plan states that a health care facility should develop and implement an internal infections plan that should be established for the purpose of improving the health and safety of residents and health care workers and should include a multidisciplinary committee including a representative from the community.

The facility policy, "The Infection Prevention and Control Committee" (revised March 2009) states that the primary objective of the Infection Prevention and Control Program is to provide an effective facility-wide program for the surveillance, prevention, and control of infection. The Infection Prevention and Control Committee meats at least quarterly to identify and analyze infection prevention and control management issues, and develops recommendations for a prompt resolution.

Interview of the Infection Control Preventionist on February 5, 2020 at approximately 10:45 a.m., revealed that in infection control meetings held on September 19, 2019, October 24, 2019 and November 21, 2019, the committee meeting attendance records revealed the following personal were not in attendance:
September 19, 2019- Community person
October 24, 2019- Community person
November 21, 2019- Community person

The facility failed to comply with the requirements of Act 52 of 2007: Medical Care Availability and Reduction of Error (MCARE) Act.

Plan of Correction - To be completed: 04/05/2020

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

It is the goal of the facility to comply with the requirements of Act 52 of 2007 Medical Care Availability and Reduction of Error (MCARE) Act.

The facilities Infection Control Committee now has a community member.

The Community Member attended the last Infection Control meeting on February 20, 2020.

The facility Assistant Administrator or designee will audit attendance of the Community Member at the Infection Control Committee meetings. Such audit will take place monthly x 4 months.

The results of the Audit will be brought to the QAPI committee to determine if additional audits are needed.

To be monitored by the Assistant Nursing Home Administrator or designee.

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