Nursing Investigation Results -

Pennsylvania Department of Health
NORMANDIE RIDGE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
NORMANDIE RIDGE
Inspection Results For:

There are  80 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.
NORMANDIE RIDGE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid, State Licensure and Civil Rights Survey completed on September 5, 2019, it was determined that Normandie Ridge was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.





 Plan of Correction:


483.10(j)(1)-(4) REQUIREMENT Grievances: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(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 observation and interviews it was determined that the facility failed to identify and prominently post information identifying a Grievance Official with whom a grievance can be filed and publish his or her contact information in one resident living area observed (resident living room bulletin board).

Findings Include:

Observations of the resident living room bulletin board, on September 3, 2019, at 10:16 AM revealed no posted information regarding the grievance official or his or her contact information.

Interviews with residents during the resident council group meeting, held on September 4, 2019, at 10:00 AM revealed residents did not know with whom to file a grievance or have knowledge of any contact information.

An interview with the Nursing Home Administrator, on September 5, 2019, at 9:01 AM confirmed no grievance official information had been posted in the resident living area.

28 Pa. Code 201.18(b)(1)(2) Management

28 Pa. Code 201.29(a)(i) Resident rights























 Plan of Correction - To be completed: 11/04/2019

1. No residents were negatively affected by this deficiency. Facility did post the grievance official sign during the survey process.
2. Grievance Official sign was posted on each of the facility's three floors.
3. Facility will re-educate staff regarding the grievance process. Will review resident's rights in filing a grievance, and inform residents of the posters on each floor with the next resident council meeting.
4. Nursing Home Administrator/or designee will audit each floor once per week x4 weeks, then monthly x2 months to ensure posters are on each floor. Results of audits will be reviewed monthly at QAPI to ensure quality assurance and compliance.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(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 clinical record review and staff interview it was determined that the facility failed to notify the resident/resident representative of a resident's transfer in writing to include; the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman for one of 32 resident records reviewed (Resident 17).

Findings include:

Review of Resident 17's clinical record revealed diagnoses that included: repeated falls, muscle weakness and unsteadiness on feet.

Further review of Resident 17's clinical record revealed a transfer to the hospital on May 9, 2019, and was admitted to the hospital with a closed fracture (cracking or breaking of a hard object) to the right femur (thigh bone) status post fall.

Review of interdisciplinary notes for Resident 17 revealed a note dated May 9, 2019, at approximately 2:07 PM which stated Resident 17 was transferred at 1:20 PM, the bed hold policy sent upon transfer, and resident representative was notified, and reason for transfer was fall with injury.

Surveyor requested a copy of the transfer notice, and it was not provided. During an interview with the Nursing Home Administrator on September 5, 2019, at approximately 9:20 AM it was revealed that the transfer notice for Resident 17 was not completed and provided to the Resident Representative or to the Resident.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited: 10/11/18


 Plan of Correction - To be completed: 11/04/2019

1. Facility is not able to retroactively correct this concern.
2. Review of the last three months of transfers/discharges to hospital, or higher level of care, will be completed to ensure no other residents were affected by this concern.
3.Re-education on F623 regulatory requirement will be provided to staff responsible for completing transfer forms.
4. Social Worker/or designee will audit all transfers weekly x4 weekly, and then monthly x2 months to ensure appropriate transfer forms are completed. Results of audits will be reviewed monthly at QAPI to ensure quality assurance and compliance.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:


Based on clinical record review and staff interviews it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for three of 33 residents reviewed (Resident 23, 38, and 49).

Findings Include:

Review of Resident 23's September 2019, physician orders revealed diagnoses that included glaucoma (a condition of increased pressure within the eyeball, causing gradual loss of sight) and hypertension (elevated blood pressure).

Review of Resident 23's annual Minimum Data Set (MDS-a tool used to assess all care areas specific to the resident), dated April 30, 2019, revealed Resident 23 triggered in the Care Area Assessment (CAA- provides guidance on how to focus on key issues identified during a comprehensive MDS assessment) for Visual Function.

Review of the CAA Summary revealed a staff decision to proceed to the plan of care and develop a care plan to address Resident 23's diagnosis of glaucoma.

Review of Resident 23's interdisciplinary plan of care revealed no care plan developed to address Resident 23's glaucoma or visual function.

An interview with the Director of Nursing (DON) on September 4, 2019, at 12:09 PM revealed no vision care plan had been developed by staff and implemented in Resident 23's interdisciplinary plan of care.

Review of Resident 38's clinical record revealed diagnosis that included dementia (symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and hypertension (a condition in which the force of the blood against the artery walls is too high).

Review of Resident 38's current physician orders revealed orders for Lexapro (an antidepressant) 10 mg once daily and Risperdal (an antipsychotic) 0.5 mg once daily in the morning and 0.75 mg once daily in the evening.

Review of Resident 38's care plan failed to reveal any care plan as of September 3, 2019, for the use of psychotropic medications was developed.

During an interview with the Director of Nursing on September 5, 2019, at 11:45 AM, she stated that she would expect Resident 38's care plan to address the resident's use of psychotropic medications and when she did not find one a new care plan was created for the resident.

Review of Resident 49's clinical record revealed diagnoses thart included Intestinal Abscess and Pancreatic Cyst.

Further review of Resident 49's clinical record revealed that her physician ordered Hospice services on August 26, 2019, and clinical progress note review revealed that she was admitted to Hospice services on the same date.

Review of Resident 49's care plan that was active on September 3, 2019, at approximately 2:00 PM failed to reveal the presence of a care plan for Hospice services. Review of a binder located on Resident 49's nursing unit containing information specific to Resident 49's Hospice services, also failed to reflect the presence of a Hospice Care Plan.

During an interview with Director of Nursing (DON) on September 4, 2019, at 1:58 PM, the DON revealed that a Hospice care plan had not been developed for either the facility's use or for the Hospice Service's use and also revealed the expectation that one should have been developed.

28 Pa. Code 211.11(d) Resident care plan

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















 Plan of Correction - To be completed: 11/04/2019

1. Visual care plan was created for resident #23. Psychotropic medications care plan was created for resident #38. Hospice care plan was created for resident #49.
2. Residents last comprehensive assessment will be reviewed to ensure that care plans are in place for items triggering under the CAA assessments.
3. Re-education will be provided to the Inter-disciplinary team regarding appropriate care planning after completion of CAA's on comprehensive MDS's. The MDS Coordinators will ensure that care plans are in place with each CAA as deemed necessary, upon completion of the comprehensive assessment.
4. MDS Coordinator/designee will audit 5 resident care plans weekly x4 weeks, then 12 residents monthly x2 months to ensure appropriate care plans are in place. Results of audits will be reviewed monthly at QAPI to ensure quality assurance and compliance.

483.40(a)(1)(2) REQUIREMENT Sufficient/Competent Staff-Behav Health Needs: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.
483.40(a) The facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with 483.70(e). These competencies and skills sets include, but are not limited to, knowledge of and appropriate training and supervision for:

483.40(a)(1) Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, that have been identified in the facility assessment conducted pursuant to 483.70(e), and
[as linked to history of trauma and/or post-traumatic stress disorder, will be implemented beginning November 28, 2019 (Phase 3)].

483.40(a)(2) Implementing non-pharmacological interventions.
Observations:


Based on clinical record review, facility documentation review, staff and resident interview, it was determined that the facility failed to provide care and services to attain or maintain the highest practicable mental health and psychosocial well being for one of four residents reviewed for psychotropic medications (Resident 41).

Findings include:

Review of Resident 41's clinical record on September 3, 2019, at approximately 1:00 PM, revealed diagnoses including major depressive disorder (mental health disorder characterized by chronic low mood which can affect energy, sleep patterns, and interest in pleasurable activities) and hypertension (high/elevated blood pressure).

Review of Resident 41's physician orders on September 3, 2019, at approximately 1:00 PM, revealed a physician order for duloxetine delayed release (antidepressant medication used to treat depression) 60 milligrams (mg - metric unit of measure) once a day for depression, dated July 29, 2019, and seroquel (antipsychotic medication used to treat psychiatric conditions), dated July 29, 2019.

Review of Resident 41's interdisciplinary notes revealed that, on July 29, 2019, at approximately 9:26 PM, staff documented that "At start of shift, resident was irate with being in the facility. She was yelling at staff. She has since calmed down."

Review of Resident 41's admission Minimum Data Set (MDS - assessment tool utilized to identify a resident's physical, emotional, and psychosocial needs), dated August 5, 2019, revealed that section D - Mood, was completed via an interview with Resident 41, and Resident 41 scored an 11 on the structured PHQ-9 interview (interview to assess a residents mood symptoms and frequency to identify if further follow-up is indicated), indicating "moderate depression."

During an interview with Resident 41 on September 5, 2019, at approximately 12:50, Resident 41 became tearful when discussing how she felt. Resident 41 revealed that she had felt increasingly depressed since arriving at the facility. Resident 41 stated that her increased depression was due to being away from home. Resident 41 acknowledged that she was currently taking the two aforementioned medications and that, prior to the hospitalization [date not disclosed] she had been under the care of a counselor, psychologist, or psychiatrist for depression and mood concerns. Resident 41 was asked if she would accept a referral to speak to someone about her increased depression, and Resident 41 stated, "yes, I would like that."

Review of Resident 41's clinical record revealed no psychological services were ordered by the physician, nor were any referrals requested for psychological services to be provided to Resident 41.

During a staff interview on September 5, 2019, at approximately 1:30 PM, the Nursing Home Administrator revealed that it was the facility's expectation that psychological services are offered to residents in need; further, that as a result of the assessment score of 11 on the Admission MDS, it was the facilities expectation that there would have been follow-up with Resident 41 to address her depression.


28 Pa Code 211.12 (d)(2)(3)(5) Nursing services






 Plan of Correction - To be completed: 11/04/2019

1.Resident #41 was offered a referral for outside psychological services. Resident initially declined, but has since accepted outpatient services. Referral pending at this time.
2. Residents with psychiatric diagnosis were reviewed and offered psychological services.
3. Facility will re-educate licensed staff on regulatory requirements and policy of F0741. Facility will review residents with psychiatric diagnosis at the time of admission and offer psychological/psychiatric services. Additionally, any resident with a new psychiatric diagnosis post admission will be offered psychological/psychiatric services.
4. DON/designee will audit all new admissions and current residents for new psychiatric diagnoses weekly x4 weeks and then monthly x2 months to ensure appropriate services are being offered to meet their mental health needs. Results of audits will be reviewed at QAPI to ensure quality assurance and compliance.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
483.45(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, facility documentation review, and staff interview, it was determined that the facility failed ensure residents were free from psychotropic medications by failing to assess the appropriateness of psychotropic medications for one of four residents reviewed for unnecessary medications (Resident 41).

Findings include:

Review of facility policy and procedure titled, "Behavior Management Program," last revised December of 2018, revealed it stated, "It is the policy of [the facility] to assess and treat the psychological needs of residents as part of [the facility's] commitment to the wellness of the whole person." Review of the policy revealed that the procedure during admission was to, "All residents and/or their responsible person/[power of attorney]s will be interviewed to assess the following aspects of the resident's psychological well-being [sic]; [subsection IA2] - History of any previous treatment for development disability, depression, anxiety, or other psychiatric/psychological disorder; [subsection IA3] - Inventory of current behaviors including their time of onset and intensity; [subsection IA4] - Psychotropic medication history including name, dosage, purpose, resident response, and side effects; [subsection IA5] - An interdiscpinary Behavior/Intervention Monthly Flow Record will be started on residents receiving psychoactive medications to track resident behaviors daily on each shift... "

Review of the facility "Behavior Management Program," revealed section "VII. Behavior Management Team," stated, "A. Interdisciplinary Team (IDT)/Behavior Management Team (BMT): [subsection VIIA1- The interdisciplinary Team (IDT)/Behavior Management Team (BMT) or designee will review all new admissions at their next regularly scheduled meeting..., [subsection VIIA4] - Psychocoactive medication will be evaluated by the IDT/BMT for the presence of side effects and behavioral patterns. IDT/BMT will monitor effective dose...[subsection VIIA6] - The Behavior Management Team will discuss recommendations to the physician for the gradual dose reductions or changes to the resident's psychoactive medication use, based on interdisciplinary review including the resident's [medication administration record], [interdisciplinary] notes and Monthly Behavior Tracking Record."

Review of Resident 41's clinical record on September 3, 2019, at approximately 1:00 PM, revealed diagnoses including major depressive disorder (mental health disorder characterized by chronic low mood which can affect energy, sleep patterns, and interest in pleasurable activities) and hypertension (high/elevated blood pressure).

Review of Resident 41's physician orders on September 3, 2019, at approximately 1:00 PM, revealed a physician order for duloxetine delayed release (antidepressant medication used to treat depression) 60 milligrams (mg - metric unit of measure) once a day for depression, dated July 29, 2019, and seroquel (antipsychotic medication used to treat psychiatric conditions), dated July 29, 2019.

Review of Resident 41's admission Minimum Data Set (MDS - assessment tool utilized to identify a resident's physical, emotional, and psychosocial needs), dated August 5, 2019, revealed that section D - Mood, was completed via an interview with Resident 41, and Resident 41 scored an 11 on the structured PHQ-9 interview (interview to assess a residents mood symptoms and frequency to identify if further follow-up is indicated), indicating "moderate depression."

Review of the physician's initial comprehensive evaluation (admission assessment) progress, dated July 31, 2019, revealed that the physician did not address the use of an antidepressant nor an antipsychotic medication in the assessment or plan for Resident 41.

Review of Resident 41's clinical record revealed that the facility initial psychosocial assessment performed upon admission by social services revealed it did not list seroquel as one of the psychoactive medications Resident 41 was taking.

Review of Resident 41's clinical record revealed that the facility did not identify Resident 41's target symptoms for the aforementioned seroquel medication, nor did the facility implement the "Behavior Management Program," to evaluate the appropriateness of the psychotropic medications.

During a staff interview on September 5, 2019, at approximately 12:50 PM, the Nursing Home Administrator revealed that it was the facility's expectation that the policies and procedures outlined in the "Behavior Management Program," be followed and implemented to evaluate the use of psychotropic medications.

28 Pa Code 211.12 (d)(2)(3)(5) Nursing services



 Plan of Correction - To be completed: 11/04/2019

1. Facility cannot retroactively correct this concern on Resident #41's clinical record as documentation on physician initial progress note and social workers initial psychosocial assessment cannot be altered. Resident #41s Cymbalta and Seroquel use were reviewed by the pharmacist during an offsite medication regimen with no changes by the physician. Resident was reviewed on September 27, 2019 at Behavior Management Meeting for appropriateness of the psychotropic medications. Care plan has been updated to reflect current behaviors/mood.
2. Residents with psychiatric diagnosis will be reviewed for physician assessment or documentation in physician progress notes. In addition, psychosocial assessments performed by the social worker on admission will be reviewed for accuracy in regards to psychiatric diagnoses.
3. Physician and Physician Assistant will be educated on thorough documentation of psychiatric diagnosis with ordered medications. Social worker will be educated on importance of obtaining accurate/complete documentation of psychosocial history, including medication use, on admission. New admissions on psychotropic medications will be added to next Behavior Management Meeting for further review.
4. DON/designee will audit new admissions for psychiatric diagnosis to ensure physician progress notes and social workers psychosocial assessment reflects appropriate diagnoses and medications in documentation. DON/designee will audit all new admissions weekly x4 weeks, then 8 monthly x2 months. Results of audits will be reviewed at QAPI to ensure quality assurance and compliance.

483.60(a)(3)(b) REQUIREMENT Sufficient Dietary Support Personnel: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.
483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.60(a)(3) Support staff.
The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in 483.21(b)(2)(ii).
Observations:


Based on review of select facility policies, Dietary Services job descriptions, other select document reviews, observations, and staff interviews it was determined that the facility failed to provide education to two out of two Dietary Services Staff Members observed regarding the procedures for using the three-compartment manual ware washing sink in the main kitchen and the dish machine in main facility kitchen (Employee DS 1 and DS 2)

Findings include:

During entrance tour with Executive Chef (EC) 1 in the main facility kitchen on September 3, 2019, at 9:40 AM, it was observed that the dish machine was starting up as three racks of dishware were going through the machine. It was observed that the final rinse temperature was 127 degrees Fahrenheit (F). It was observed that Dietary Server (DS) 2 was sending through the dirty dishes and that Dietary Server (DS) 2 was working the clean end of the dish machine. DS 2 was observed to send the first rack of dishware that had been sent through a second time (normal practice) and again it was observed by surveyor that the final rinse temperature was at 127 degrees F. At this time, EC 1 advised DS 1 and 2 to shut down the machine and use the three compartment sink. No observation was made of DS 1 or DS 2 observing the dish machine temperatures in order to determine when they were at required temperatures.

Review of form Dishwashing/Warewashing Machine Temperature Logs for August and September 2019, to date, revealed that final rinse temperatures for the dish machine are to be 180 degrees F. Further review of the form revealed that dish machine temperatures for wash and final rinse were being consistently taken following the breakfast meal and that all were at proper temperatures. However it was noted that no temperatures were recorded for the midday meal and that temperatures for the evening meal were not complete for 11 of 31 days in August and that nine of the 21 recorded final rinse temperatures were below 180 degrees F.

An additional observation was made at 9:55 AM that the three-compartment sink had been set up and that DS 1 was working the wash sink. At this time EC 1 was requested to take the temperature of the wash sink (which is required to be a minimum of 110 degrees F). The wash water temperature was taken as 102.5 degrees F. It was observed that a large pile of just washed dishware was on a cart alongside the sinks and that DS 1 was actively washing food containers. It was observed also that the final sink/sanitizing sink was actively being used with pans in it. EC 1 checked the sanitizer level which was observed to be satisfactory, however it was observed at this time that the sanitizer strips (used to measure for adequacy of amount of sanitizer solution in the water via a color change) had an expiration date of February 1, 2019.

At time of reviewing three compartment sink, Dietary General Manager (GM) 1 arrived. GM 1 was interviewed regarding incompleteness of dish machine temperature logs. GM 1 revealed that they are only required to check dish machine temperatures at one meal per day. GM 1 was interviewed regarding what action would be taken and/or follow-up if dish machine temperatures not up to par and GM 1 stated that staff would be spoken to. GM 1 also revealed that he believed there was no documentation of education with staff members when temperatures are low.

During an interview with DS 1 on September 4, 2019, at 10:23 AM, DS 1 revealed that she has been working in the kitchen for 11 years and has never had training on using the dish machine or three compartment sink. DS 1 shared that the company that responds to dish machine maintenance needs was in the day before (date of concern regarding temperatures). The dish machine was observed to be running for use during this interview at acceptable temperatures.

Review of maintenance invoice for dishmachine dated for September 3, 2019, (date of observation of machine not working properly) starting at 12:15 PM. revealed "checked and found that there was no power to the booster heater(special type of water heater typically used with dishwashers to heat rinse water to proper sanitizing temperatures) ; reset the breaker... shut down machine...found that the left side contractor for the booster was stuck..shut down the breakers and replaced both of the boosters' contractors."

In summary, DS 1 and DS 2 were not observed to be monitoring the final rinse temperature of the dish machine and stopped running it due to being observed. On same date (September 3, 2019,) maintenance intervention revealed there was in fact a problem with the booster heater.

Review of Dietary Services Competency Evaluation-Servers/Food Service Worker for DS 1 and DS 2 were reviewed. Review of DS 1 Evaluation completed on March 18, 2019, revealed under "Take dish upstairs on a covered cart and run them through the dish machine and Return them to the dining room in a covered cart." that DS 1 scored a rating of 1 (code for Unsatisfactory). Facility was unable to provide any information that DS 1 received additional education to become satisfactory with this job task. Review of DS 2 Employee Competency Evaluation-Cook dated February 16, 2017, did not include use of dish machine in job tasks and the task of "Demonstrates how to test sanitizer solution" was not evaluated.

During an interview with Nursing Home Administrator (NHA) on September 5, 2019, at 1:22 PM, the NHA revealed the expectation that staff would have satisfactory training for their assigned job tasks.

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.

28 Pa. Code 211.6(c) Dietary services.































 Plan of Correction - To be completed: 11/04/2019

1. Facility provided verbal education to DS1 and DS2 at the time of the identified concern. The dish machine was repaired from an outside contractor that same day.
2. Facility continued to monitor the operation of the dish machine after repair to ensure appropriate sanitation to 180 degrees. No concerns noted.
3. Re-education will be provided to dining services staff regarding appropriate use and sanitation related to the three bay sink, the dishwasher, and recording dishwasher temps after each meal. Competency evaluation will be completed on Dining Services staff to ensure staff is competent in job responsibilities. Additionally, competencies will be completed on all dining services staff annually. If staff scores unsatisfactory in any area, additional training will be provided until competency can we demonstrated.
4. Dining Services Manager/designee will audit temperature logs 5x/week for 4 weeks, then 15 monthly for two months to ensure dishwasher is at appropriate sanitizing temperatures. Results of audits will be reviewed at QAPI to ensure quality assurance and compliance.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:


Based on observations and staff interviews, it was determined that the facility failed to follow policy to ensure sanitation of dishware in the main facility kitchen dish machine and in one of one three-compartment sink in accordance with professional standards for food service safety.

Findings include:

During entrance tour with Executive Chef (EC)1 in the main facility kitchen on September 3, 2019, at 9:40 AM, it was observed that the dish machine was starting up as three racks of dishware were going through the machine. It was observed that the final rinse temperature was 127 degrees Fahrenheit (F). It was observed that Dietary Server (DS) 2 was sending through the dirty dishes and that Dietary Server (DS) 2 was working the clean end of the dish machine. DS 2 was observed to send the first rack of dishware that had been sent through a second time (normal practice) and again it was observed that the final rinse temperature was at 127 degrees F. At this time, EC 1 advised DS 1 and 2 to shut down the machine and use the three compartment sink.

Review of form Dishwashing/Warewashing Machine Temperature Logs for August and September 2019, to date, revealed that final rinse temperatures for the dish machine are to be 180 degrees F. Further review of the form revealed that dish machine temperatures for wash and final rinse were being consistently taken following breakfast meal and that all were at proper temperatures. However it was noted that no temperatures were recorded for the midday meal and that temperatures for the evening meal were not complete for 11 of 31 days in August and that nine of the 21 recorded final rinse temperatures were below 180 degrees F.

As entrance tour continued, observation was made at 9:55 AM that the three-compartment sink had been set up and that DS 1 was working the wash sink. At this time EC 1 was requested to take the temperature of the wash sink (which is required to be a minimum of 110 degrees F). The wash water temperature was taken as 102.5 degrees F. It was observed that a large pile of just washed dishware was on a cart alongside the sinks and that DS 1 was actively washing food containers. It was observed also that the final sink/sanitizing sink was actively being used with pans in it. EC 1 checked the sanitizer level which was observed to be satisfactory. It was observed at this time that the sanitizer strips (used to measure for adequacy of amount of sanitizer solution in the water via a color change) had
an expiration date of February 1, 2019.

At time of reviewing three compartment sink, Dietary General Manager (GM) 1 arrived. GM 1 was interviewed regarding incompleteness of dish machine temperature logs. GM 1 revealed that they are only required to check dish machine temperatures at one meal per day. GM 1 was interviewed regarding what action would be taken and/or follow-up if dish machine temperatures not up to par and GM 1 revealed stated that staff would be spoken to. GM 1 also revealed that he believed there was no documentation of education with staff members when temperatures are low.

During an interview with DS 1 on September 4, 2019, at 10:23 AM, DS 1 revealed that she has been working in the kitchen for 11 years and has never had training on using the dish machine or three compartment sink. DS 1 shared that the company that responds to dish machine maintenance needs was in the day before (date of concern regarding temperatures). The dish machine was observed to be running for use during this interview at acceptable temperatures.

Review of Section D. Sanitation of the facility document "Food Safety Standards & Requirements with most recent revised date of March 27, 2019, revealed "The hot water final rinse, in a high temperature dish machine, must be checked at the beginning of each meal period and documented on the Dishwashing/Warewashing Machine Temperature Log."

Review of maintenance invoice for dishmachine dated for September 3, 2019, (date of observation of machine not working properly) starting at 12:15 PM. revealed "checked and found that there was no power to the booster heater(special type of water heater typically used with dishwashers to heat rinse water to proper sanitizing temperatures) ; reset the breaker... shut down machine...found that the left side contractor for the booster was stuck..shut down the breakers and replaced both of the boosters' contractors."

During an interview with Nursing Home Administrator (NHA) on September 5, 2019, at 9:41 AM, the NHA revealed the expectation that dishmachine temperatures should be taken for use after each meal and that she would expect follow-up documentation to address the status of the dish machine when temperatures are reading low. NHA also revealed the expectation that the three compartment sink waters temperatures would be at required levels and that expired sanitizing test strips would not be used.

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

28 Pa. Code 201.18(b)(3) Management.




































 Plan of Correction - To be completed: 11/04/2019

1. Facility provided verbal education to DS1 and DS2 at the time of the identified concern. The dish machine was repaired from an outside contractor the same day. Expired sanitizer strips were discarded and new ones were ordered.
2. Facility continued to monitor the operation of the dish machine after repair to ensure appropriate sanitation to 180 degrees. No concerns noted.
3. Re-education will be provided to dining services staff regarding appropriate use and sanitation related to the three bay sink, the dishwasher, recording dishwasher temps after each meal, ensuring sanitizer test strips are not expired prior to use.
4. Dining Services Manager/designee will audit temperature logs 5x/week for 4 weeks, then 15 monthly for two months to ensure dishwasher is at appropriate sanitizing temperatures. Sanitizer test strips will also be audited once a week x4 weeks, then monthly x2 months to ensure they are not expired. Results of audits will be reviewed at QAPI to ensure quality assurance and compliance.

483.70(o)(1)-(4) REQUIREMENT Hospice Services: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.
483.70(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 interviews, it was determined that the facility failed to ensure that there was a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the Long Term Care facility before hospice care is furnished to any resident for two of six Hospice residents reviewed (Residents 17 and 49).

Findings include:

Review of Resident 17's clinical record revealed diagnoses that included: repeated falls, muscle weakness and unsteadiness on feet.

Review of Resident 17's care plan revealed a focus area for hospice/palliative care with a start date of August 15, 2019.

Review of the agreement between the facility and the Hospice Care agency (a provider of end of life services) 1, revealed that February 25, 2015, was the date of the agreement, and the term of the agreement was for one year beginning February 25, 2015, and that the agreement would renew automatically for three years after the first year, expiring February 24, 2019 .

During an interview with the Nursing Home Administrator on September 5, 2019, at approximately 9:18 AM it was revealed that the facility couldn't find an active contract with Hospice Care agency 1 on file, and contacted Hospice Care agency 1 for a copy of the contract.

Review of the agreement between the facility and Hospice Care agency 1 revealed that the agreement was initiated (effective date) on September 4, 2019.

During an interview with the Nursing Home Administrator (NHA) on September 5, 2019, at approximately 9:30 AM revealed that the NHA wanted to follow up with Hospice Care agency 1 to verify if the contract had lapsed.

During an interview with the NHA on September 5, 2019, at approximately 11:00 AM it was revealed that the Hospice Care agency 1 contract had lapsed, and was initiated on September 4, 2019. It was also revealed that Residents 17 and 49 had received hospice services from Hospice Care agency 1 during the time period the agreement had lapsed.

Review of Resident 49's clinical record revealed diagnoses that included Intestinal Abscess and Pancreatic Cyst.

Further review of Resident 49's clinical record revealed that her physician ordered Hospice services from Hospice Care agency 1 on August 26, 2019, and clinical progress note review revealed that she was admitted to Hospice services on the same date.

During an interview with the Nursing Home Administrator (NHA) on September 5, 2019, at approximately 9:18 AM it was determined that the NHA was unable to locate an active contract on-site. Review of a contract provided by Hospice Service 1 on September 5, 2019, revealed a written signed contract between the facility and Hospice Service 1 which revealed a contract initiation date of September 4, 2019.

During an interview with the NHA on September 5, 2019, at approximately 11:00 AM, the NHA confirmed that Hospice Service 1 corroborated that the above described contract had lapsed and was renewed on September 4, 2019. At this time, the NHA revealed the expectation that the contract should not have lapsed.

28 Pa code 201.18(e)(1) Management









 Plan of Correction - To be completed: 11/04/2019

1. No residents were adversely affected by this concern. A new hospice contract from Hospice Service 1 was obtained during the time the concern was identified.
2. Facility will review all hospice contracts to ensure they are current without lapse in contractual agreement.
3. Re-education will be provided to administrative staff, and hospice agencies, to ensure contracts are kept current.
4. Nursing Home Administrator/designee will audit hospice contracts annually to ensure they are not expired. Results of audit will be reviewed at QAPI to ensure quality assurance and compliance.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:


Based on observation and interview, it was determined that the facility failed to maintain a safe and sanitary environment that supports infection prevention and control for one of one medication /medical supply storage room within the facility.

Findings include:

A review of the facility policy titled, "Medication Storage in the Facility," last revised May 2003, stated that outdated, contaminated, or deteriorated medications and those containers that are cracked, soiled, or without secure closures are immediately removed from stock, and disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists. During an interview with the Nursing Home Administrator on September 5, 2019, she stated that all medications and medical supplies stored in the medication room that are outdated, contaminated, or deteriorated should be managed the same.

During observation of the medication/medical supply storage room on September 5, 2019, at 10:08 AM, the following supplies were observed to be expired;

C1000 Clave connectors (needleless connector), 6 packages with 1 each expired 10/2017 (October 2019).
C1000 Clave connector (needleless connector), 1 package of 1 expired 01/2019 (January 2019).
Universal viral transport for viruses, 9 packages of 1 each expired 09/2018 (September 2018).
IV administration sets, 3 sets expired 08/2017 (August 2017).
Gastro-cult solution, (Testing Solution) 4 solutions expired 07/2019 (July 2019).
Gastro-cult solution, (Testing Solution) 1 solution expired 02/2019 (February 2019).
Hemocult (blood in stool) test cards, 47 cards expired 02/2019 (February 2019).

During an interview with the Nursing Home Administrator on September 5, 2019, she confirmed that supplies should not be expired, and if expired, should be discarded.

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







 Plan of Correction - To be completed: 11/04/2019

1. The identified expired supplies were immediately removed from the medication storage room and discarded properly.
2. Facility audited all supplies and medication in medication storage/supply closet to en-sure there were no expired medications or supplies.
3. Re-education will be provided to licensed nursing staff regarding appropriate disposal of expired medications and supplies. Night Shift Supervisor/designee will complete an audit once/week and dispose of any expired medications/supplies.
4. DON/Designee will audit medication room and supply storage to ensure proper expira-tion dates weekly x4 weeks and then twice monthly, x2 months. Results of audits will be reviewed monthly at QAPI to ensure quality assurance and compliance.


483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations: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.
483.80(d) Influenza and pneumococcal immunizations
483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
Observations:


Based on record review and interview, it was determined that the facility failed to offer an influenza immunization for one of five residents reviewed, (Resident 2).

Findings include:

A review of the clinical record for Resident 2 on September, 5, 2019, revealed she was admitted to the facility from the community on November 23, 2018.

A review of Resident 2's Admission MDS (Minimum Data Set-periodic assessment of the resident) dated December 7, 2018, revealed Section O0250 Influenza Vaccine, Code box A. was coded a 0 (zero), indicating the resident did not receive the influenza vaccine in the facility. Code box C was coded a 5 (five) indicating the influenza vaccine was not offered.

A review of Resident 2's Quarterly MDS dated February 27, 2019, revealed it was also coded that the influenza vaccine was not offered.

A review of the Quarterly MDS dated May 23, 2019, which partially included influenza season (October 1, 2018, through March 31, 2019), was also coded that the influenza vaccine was not offered.

During an interview with the Nursing Home Administrator on August 5, 2019, she revealed there was no record that the influenza vaccine was ever offered to Resident 2, and there was no history of the influenza vaccine being administered to Resident 2 prior to her admission to the facility.

28 Pa. Code 201.18(a)(b)(1) Management.













 Plan of Correction - To be completed: 11/04/2019

1. Facility cannot retroactively correct this deficiency for resident #2 for the 2018-2019 flu season.
2. Current residents have updated consents on file for current flu season.
3. Re-education on flu policy will be provided to licensed nursing staff. If residents are found to be without current flu immunizations at the time of admission during flu season, Infection Control Nurse/designee will offer immunization to resident.
4. Infection Control Nurse/designee will complete audit of new admissions flu consent and immunization weekly x 4 weeks and then 10 monthly x2 months. Results of audits will be reviewed monthly at QAPI to ensure quality assurance and compliance.


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