Pennsylvania Department of Health
TREMONT HEALTH & REHABILITATION CENTER
Patient Care Inspection Results

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TREMONT HEALTH & REHABILITATION CENTER
Inspection Results For:

There are  132 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.
TREMONT HEALTH & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated survey in response to a complaint completed on December 13, 2024, it was determined that Tremont Health and Rehabilitation Center was not in compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 13 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from November 20 through December 10, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 10 residents on day shift (7:00 a.m. to 3:00 p.m.) on November 30 and December 7 and 8, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 11 residents on evening shift (3:00 p.m. to 11:00 p.m.) on November 22, 23, 28, and 30, and December 8 and 9, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on November 23, 25, 27, and 29, and December 1, 5, and 6, 2024.


 Plan of Correction - To be completed: 01/23/2025

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.
1) The facility cannot retroactively correct the past C.N.A Ratios
2) Moving forward, the facility will continue to make good faith effort to schedule staff to meet or exceed the mandated ratios of One NA to 10 residents on day shift; one NA to 11 residents on evening shift and one NA to 15 residents on night shift. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios.
The facility contracts with agencies to supply aides to meet requirements but call offs and no-show result in unmet ratios. The facility is working to hire and train staff to achieve the minimum staffing ratios for nurse aides. The facility offers bonuses to staff to encourage staff to pick up additional shifts.
3)To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated staffing regulations in relation to the minimum ratio of one NA to 10 residents on days, one NA to 11 residents on evenings and one NA to 15 residents on nights.. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum ratios. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies.
4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum NA ratios. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for 10 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from November 20 through December 10, 2024, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on day shift (7:00 a.m. to 3:00 p.m.) on November 23, 24, and 28, and December 7 and 8, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 30 residents on evening shift (3:00 p.m. to 11:00 p.m.) on December 4 and 7, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11:00 p.m. to 7:00 a.m.) on November 21, 23, 27, and 30, and December 3 and 4, 2024.


 Plan of Correction - To be completed: 01/23/2025

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

1) The facility cannot retroactively correct the past LPN Ratios
2) Moving forward, the facility will continue to make good faith effort to schedule staff to meet or exceed the mandated ratios of One LPN to 25 residents on day shift; one LPN to 30 residents on evening shift and one LPN to 40 residents on night shift. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios.
The facility contracts with agencies to supply LPN's to meet requirements but call offs and no-shows result in unmet ratios. The facility is working to hire and train staff to achieve the minimum staffing ratios for LPN's. The facility offers bonuses to staff to encourage staff to pick up additional shifts.
3)To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated staffing regulations in relation to the minimum ratio of one LPN to 25 residents on days, one LPN to 25 residents on evenings and one LPN to 40 residents on nights.. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum ratios. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies.
4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum NA ratios. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 3.2 hours of direct care for each resident for eight of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from November 20 through December 10, 2024, revealed the following total nursing care hours below minimum requirements:

November 23, 2024: 2.68 care hours per resident.
November 27, 2024: 3.15 care hours per resident.
November 28, 2024: 3.07 care hours per resident.
November 29, 2024: 3.18 care hours per resident.
November 30, 2024: 2.90 care hours per resident.
December 1, 2024: 2.94 care hours per resident.
December 7, 2024: 3.12 care hours per resident.
December 8, 2024: 3.11 care hours per resident.


 Plan of Correction - To be completed: 01/23/2025

1) The facility cannot retroactively correct the staffing PPD issues.
2) The facility utilizes staffing agencies, bonuses for staff and actively recruiting for new staff. Management staff is utilized to achieve mandated staffing requirements.
3) To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated staffing regulations in relation to the daily PPD of 3.2 hours. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum PPD. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies. The deployment sheets are developed in advance so staffing challenges can be addressed. A good faith effort is made to achieve the mandated staffing requirements. Supervisors are educated on the importance of filling call offs to meet requirements.
4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum PPD. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.


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