Pennsylvania Department of Health
GUARDIAN HEALTHCARE MEADOWCREST
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GUARDIAN HEALTHCARE MEADOWCREST
Inspection Results For:

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GUARDIAN HEALTHCARE MEADOWCREST - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance, and Abbreviated Survey in response to a complaint completed May 16, 2024, it was determined that Guardian Healthcare Meadowcrest was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.95(d) REQUIREMENT QAPI Training:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

§483.95(d) Quality assurance and performance improvement.
A facility must include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program as set forth at § 483.75.

Observations:
Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for ten of ten staff members (Employees E1, E2, E3, E4, E5, E6, E7, E8, E9 and E10).

Findings include:

Review of the policy "Inservice Training" dated 1/4/24, with previous review date of 3/21/23, indicated it is the policy of this facility that all staff participate in regular in-service education upon hire and annually and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. Trainings included for all existing and newly hired employees include but not limited to communication, abuse, neglect, etc, the facility QAPI program and behavioral health.

Review of facility provided documents and training record for E1, E2, E3, E4, E5, E6, E7, E8, E9 and E10 revealed the following staff members did not have documented training on QAPI.

Nurse Aide (NA) Employee E1 had a hire date of 6/15/17, failed to have QAPI in-service education between 6/15/23 and 5/15/24.
Licensed Practical Nurse (LPN) Employee E2 had a hire date of 6/28/22, failed to have QAPI in-service education between 6/28/23, and 5/15/24.
NA Employee E3 had a hire date of 9/6/22, failed to have QAPI in-service education between 9/6/23, and 5/15/24.
Housekeeping Employee E4 had a hire date of 12/29/23, failed to have QAPI in-service education between 12/29/23, and 5/15/24.
Dietary Aide Employee E5 had a hire date of 7/10/23, failed to have QAPI in-service education between 7/10/23, and 5/15/24.
NA Employee E6 had a hire date of 4/8/98, failed to have QAPI in-service education between 4/8/23, and 5/15/24.
NA Employee E7 had a hire date of 5/17/17, failed to have QAPI in-service education between 5/17/23, and 5/15/24.
Maintenance Director Employee E8 had a hire date of 9/1/20, failed to have QAPI in-service education between 9/1/23, and 5/15/24.
NA Employee E9 had a hire date of 6/26/23, failed to have QAPI in-service education between 6/26/23, and 5/15/24.
Assistant Director of Nursing/ Infection Control Preventionist Employee E10 had a hire date of 8/28/23, failed to have QAPI in-service education between 8/28/23, and 5/15/24.

During an interview on 5/15/24, at 12:30 p.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to provide training on QAPI for ten of ten staff members. The NHA stated that she "contacted corporate and they indicated that QAPI had not been added to all staff trainings."

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

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

28 Pa Code: 201.20 (a)(c) Staff development.

Plan of Correction - To be completed: 06/18/2024

1.Employees E1, E2, E3, E4, E5, E6, E7, E8, E9 and E10 will be provided education on Quality Assurance and Performance Improvement (QAPI).
2. Education to be provided to current facility staff including agency staff, contracted staff and volunteers on Quality Assurance and Performance Improvement (QAPI).
3. Audits to be completed by Nursing Home Administrator/designee on new employees and annually for all staff including agency staff, contracted staff and volunteers to ensure that all new hires receive education on Quality Assurance and Performance Improvement (QAPI).
4. Audits will be conducted weekly X four weeks, then monthly x two months. The results of these audits will be reported to Facility's Monthly QAPI meeting until compliance is met.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:

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(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Observations:
Based on review of the facility policy, clinical records, and staff interviews it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for five of six residents reviewed (Resident R1, R2, R12, R20, and R35)

Findings Include:

A review of the facility policy "Advanced Directives" reviewed 3/21/23 and 1/4/2024, indicated advance directives will be respected in accordance with state law and facility policy. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.

A review of the clinical record indicated Resident R1 was re-admitted to the facility on 11/18/22, with diagnoses that included diabetes, Non- ST Elevation Myocardial Infarction (NSTEMI- type of heart attack that usually happens when your heart ' s need for oxygen can ' t be met), and congestive heart failure (CHF - the heart is unable to pump blood throughout the body efficiently).

A review of the clinical record failed to reveal an advance directive or documentation that Resident R1 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R2 was admitted to the facility on 1/26/21, with diagnoses that include cerebral palsy (group of disorders that affect a person ' s ability to move and maintain balance and posture), functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord), and high blood pressure.

A review of the clinical record failed to reveal an advance directive or documentation that Resident R2 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R12 was admitted to the facility on 2/27/24, with diagnoses that include bone cancer, breast cancer, and difficulty swallowing.

Review of the clinical record failed to reveal an advance directive or documentation that Resident R12 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R20 was admitted to the facility on 4/11/16, with diagnoses that include anxiety, difficulty swallowing ,and repeated falls.

A review of the clinical record failed to reveal an advance directive or documentation that Resident R20 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R35 was admitted to the facility on 3/20/2024, with diagnoses that included liver cancer, cirrhosis of the liver (degenerative disease resulting in scarring and liver failure), and high blood pressure.

A review of the clinical record failed to reveal an advance directive or documentation that Resident R35 was given the opportunity to formulate an Advanced Directive.

During an interview on 5/17/24, at 9:54 a.m. the Social Services Director E11 stated she confused the POLST with Advance Directives, confirming Residents R1, R2, R12, R20, and R35 were not afforded the opportunity to formulate Advance Directives upon admissions and periodically during their stay in the facility.

During an interview on 5/17/24, at 9:55 a.m. the Nursing Home Administrator confirmed the facility failed to afford the residents the opportunity to formulate Advance Directives upon admissions and periodically during their stay in the facility.

28 Pa. Code: 201.29(b)(d)(j) Resident rights.

Plan of Correction - To be completed: 06/18/2024

1. Residents R1, R2, R12, R20 and R35 were provide opportunity to formulate an advance directive
2. The Facility's Social Worker will review/audit current residents in the facility to identify residents that were not offered the opportunity to formulate an advance directive. Those residents identified as not being offered the opportunity to formulate an advance directive were offered the opportunity to formulate an advance directive. Documentation of the offering of the opportunity to formulate an advance directive was completed by the Facility's Social Worker in the residents' medical record.
3. The Facility's Administrator will educate the Facility's Social Worker on the facility's Policy of Advance Directives to include the resident's rights to formulate an advance directive and documentation.
4. The Facility's Social Worker will audit new admissions Weekly X four weeks and then monthly X two months +to ensure residents are offered the opportunity to formulate an advance directive such as a living will or durable power of attorney for health care and documentation was completed on the offering in resident's medical record. The results of these audits will be reported to Facility's Monthly QAPI meeting until compliance is met.

483.95(i) REQUIREMENT Behavioral Health Training:

§483.95(i) Behavioral health.
A facility must provide behavioral health training consistent with the requirements at §483.40 and as determined by the facility assessment at §483.70(e).

Observations:
Based on review of staff interview and facility documents, it was determined that the facility failed to provide training on behavioral health for three of ten staff members reviewed (Employees E4, E5 and E8).

Findings Include:

Review of the policy "Inservice Training" dated 1/4/24, with previous review date of 3/21/23, indicated it is the policy of this facility that all staff participate in regular in-service education upon hire and annually and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. Trainings included for all existing and newly hired employees include but not limited to communication, abuse, neglect, etc, the facility QAPI program and behavioral health.

Review of facility provided education records for three of the ten currently employed staff members that were reviewed revealed the following:

Review of the facility provided current staff list indicated Housekeeping Employee E4 was hired on 12/29/23. housekeeping employee E4's training record for failed to include current behavioral health training.

Review of the facility provided current staff list indicated Dietary Aide Employee E5 was hired on 7/10/23. Dietary Aide Director Employee E5's training record for failed to include current behavioral health training.

Review of the facility provided current staff list indicated Maintenance Director Employee E8 was hired on 9/1/20. Maintenance Director Employee E8's training record for failed to include current behavioral health training.

During an interview on 5/15/24, at 12:30 p.m., the Nursing Home Administrator confirmed the facility failed to provide training on behavioral health for three of ten staff members reviewed.

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

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

28 Pa Code: 201.20 (a)(c) Staff development.

Plan of Correction - To be completed: 06/18/2024

.Employees E4, E5, and E8 will be provided education on Behavioral Health training.
2. Education to be provided to current facility staff including agency staff ,contracted staff and volunteers on Behavioral Health training.
3. Audits to be completed by Director of Nursing/ Designee on all new employees to ensure that all new hires receive education on Behavioral Health training.
4. Audits will be conducted weekly X four weeks, then monthly x two months. The results of these audits will be reported to Facility's Monthly QAPI meeting until compliance is met.
P1020

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee:

§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

Observations:
Based on review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members (Infection Preventionist) for three of four quarterly meeting (May 2023 through July 2023, August 2023 through October 2023, and November 2023 through January 2024).

Findings Include:

Review of the facility policy "Quality Assurance and Process Improvement Committee" (QAPI) reviewed 1/4/24, indicated that the facility will establish and maintain a QAPI committee that consists of the administrator, director of nursing, medical director, and infection control representative.

Review of QAPI sign in sheets and attendance records from May 2023 through January 2024 failed to indicate the infection control representative was in attendance for any meetings.

During an interview on 5/17/24, at 10:10 a.m. the Nursing Home Administrator confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members as required.

28 Pa Code: 201.18(e )(1)(2)(3)(4) Management.

Plan of Correction - To be completed: 06/18/2024

1.Facility will conduct an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting. Administrator to review QAPI policy and required members including Infection Preventionist on a minimum of a quarterly basis.
2. Nursing Home administrator to identify a date of monthly QAPI Meetings and notify required members of the dates.
3. Administrator to review monthly meeting minutes and signature sheets to ensure that required members are present.
4. The results of these audits will be reported to Facility's Monthly QAPI meeting until compliance is met.

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

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

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

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

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

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

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

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

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

Observations:

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to maintain a clean, homelike environment on two of two nursing units (Fawn Lane and Garden Lane) and failed to provide a homelike environment for seven of 21 residents of the Garden Lane nursing unit (Residents R24, R4, R22, R34, R25, R16 and R17).

Findings include:

Review of the facility policy " Homelike Environment", last reviewed on 1/4/24, indicated that the facility will ensure that residents are provided with a safe, clean, comfortable, homelike environment and encouraged to use their personal belongings.

During an observation on 5/14/24, from 6:32 a.m., through 7:20 a.m., the following was identified:

-The main resident lounge located on Fawn Lane nursing unit had six wheelchairs, a Hoyer lift and a floor scale which did not allow access for resident use.
-The dining room at the end of Fawn hall had a broken baseboard heating unit allowing for sharp edges to be protruding.
-The dining room of the Garden Lane nursing unit had two wheelchairs that were marked with a tag to lean 4/21/24, with debris and the large w/c had broken arm rests. A closet with personal items(shave cream, razors, mouthwash) was open and had items on the floor and was accessible to residents.
-The "emergency exit" near therapy room had six wheelchairs at exit then six wheelchairs in hall to the outer exit blocking emergency doors.

During an interview on 5/14/24, at 7:22 a.m., the Nursing Home Administrator(NHA) confirmed that the facility failed to maintain a clean, homelike environment on two of two nursing units (Fawn Lane and Garden Lane).

During a observation on 5/14/24, from 9:45 a.m., through 10:32 a.m., the following was identified:

-Resident R24's wall behind dresser, by her closet, behind her bed and behind the night stand all has areas with broken plastered walls.
-Residents R4 and R22 had broken plaster behind beds with baseboard heater unit broken, the bathroom transition strip was broken and lifted allowing for a tripping hazard and the shared closet had clothes in piles on the floor on both sides.
-Residents R34 and R25 had holes in the wall behind the beds, the floor was soiled with food debris and liquids and the shared closet had clothes in piles on the floor on both sides.
-Residents R16 and R17 floor had debris including a marker lying in the middle of the floor.

During an interview on 5/14/24, at 10:45 a.m., the NHA confirmed that the facility failed to maintain a clean, homelike environment for seven of 21 residents of the Garden Lane nursing unit (Residents R24, R4, R22, R34, R25, R16 and R17).

28 Pa. code: 201.14 (a) Responsibility of licensee.

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

28 Pa Code: 201.29 (a)(c)(d) Resident rights.

Plan of Correction - To be completed: 06/18/2024

1. The cited areas in the main resident lounge, dining room, emergency exit, resident rooms for R24, R4, R22, R34, R25, R16 and R17 were addressed.
2.Resident rooms and Resident common areas on each nursing unit were reviewed to determine appropriate storage and cleanliness to maintain a safe, clean, comfortable, homelike environment. Areas that were found to be deficient were corrected. Nursing, Maintenance and housekeeping staff were educated by the nursing home administrator on the policy and procedure for homelike environment.
3.The NHA or designee will assign random rounds to department managers to review storage, cleanliness and holes in walls. The rounds will encompass both a blend of resident rooms, common areas and exits. The rounds will be turned into the NHA or designee during morning department manager meetings. The audits will be completed randomly times 3 weeks and monthly for 2 months.
4.Results of the audits will be reported by the nursing home administrator to the monthly QAPI team meeting until compliance is met.

483.20(g) REQUIREMENT Accuracy of Assessments:

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

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:
Based on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of three residents (Resident R23).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS - mandated assessments of a resident's abilities and care needs), dated October 2023, indicated the following instructions:
-Section O: Special Treatments, Procedures, and Programs: Check all of the following treatments, procedures, and programs that were performed during the last 14 days.

Review of the clinical record indicated Resident R23 was re-admitted to the facility on 6/22/23, with diagnoses that included moderate intellectual disabilities, dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and anxiety.

Review of the MDS dated 3/22/24, confirmed Resident R23's diagnoses remain current. Review of Section O: Special Treatments, Procedures, and Programs, Question O100 K1 Hospice Care, indicated that Resident R23 did not receive hospice services while a resident at the facility.

Review of a physician's order dated 12/14/23, indicated Resident R23 was admitted to hospice services.

During an interview on 5/16/24, at 1:32 p.m. the Registered Nurse Assessment Coordinator (RNAC) Employee E13 confirmed that the MDS assessment was not completed accurately.

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing Services.

Plan of Correction - To be completed: 06/18/2024

1.Registered Nurse Assessment Coordinator corrected Section 0.100KI of resident 23's Minimum Data Set assessment to include Hospice Care.
2. Review of residents receiving Hospice Care over the past 30 days to ensure proper coding in Section 0.100K1. Registered Nurse Assessment Coordinator educated on Resident Assessment Instrument (RAI), user manual for Section 0.100K1.
3. Registered Nurse Assessment Coordinator or designee will audit Section 0.100ZK1 of Minimum Data Set for three resident's weekly times four weeks and monthly times two months.
4. The results of these audits will be reported to the Facility's Monthly QAPI meeting until compliance is met.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to prevent food items from being stored in a medication refrigerator in one of two medication rooms (Fawn Nursing Unit).

Findings include:

Review of the facility policy "Medication Labeling and Storage" dated 3/21/23 and 1/4/24, indicated medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly.

During an observation on 5/15/24, at 1:35 p.m. revealed the following two Fuji brand water bottles, one Pellegrino sparking water bottle, and one small carton of whole milk stored in the medication refrigerator in the Fawn Nursing Unit medication room.

During an interview on 5/16/24, at 1:38 p.m. the Registered Nurse Employee E13 confirmed food and drinks should not be stored in the medication refrigerator.

During an interview on 5/16/24, at 2:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to prevent food items from being stored in a medication refrigerator on Fawn Nursing Unit.

28 Pa Code: 211.9 (a) Pharmacy services.

28 Pa code: 211.12 (d) (1) (5) Nursing services.

Plan of Correction - To be completed: 06/18/2024

1.Food and drink items were immediately removed from the medication refrigerators and disposed of in both Fawn and Garden medication refrigerators. Whole house audit completed to ensure no food or drink items were being stored in any of the facility medication refrigerators.
2.Licensed nursing staff will be educated on the medication storage policy.
3.Don/ Designee will complete audits on 100% of medication refrigerators to ensure no food or drink items are being stored in the medication refrigerators weekly x 4 weeks, then monthly x two months.
4.The results of these audits will be reported to Facility's Monthly QAPI meeting until compliance is met.

§ 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 Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:
Based on review of facility records, and staff interview, it was determined that the facility failed to comply with the following requirements of MCARE Act 403(a)(1).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L. 154, No. 13), known as the Medical Care Availability and Reduction of Error (MCARE) Act, Chapter 4, Section 403(1) Infection Control plan states, "A health care facility... shall develop and implement an internal infection control plan that shall include... a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members at infection control meetings include medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plan personnel, patient safety officer, a community member, and a member of the infection control team.

Review of Infection Control meeting sign in documentation did not include signatures for the Infection Control representative for the months of May 2023, Jane 2023, July 2023, August 2023, September 2023, October 2023, November 2023, December 2023, January 2024, February 2024, and March 2024.

During an interview on 5/16/22, at 10:10 a.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to comply with all the requirements of MCARE Act 403.

Plan of Correction - To be completed: 06/18/2024

1.DON/Designee ensure that Infection Preventionist schedules an Ad Hoc Infection control meeting.
2.Current policies and protocol to be reviewed with all members to attended quarterly infection control meetings at a minimum. DON/designee also reviewed aforementioned information with representative of medical staff, administration, nursing staff, pharmacy staff, physical plant personnel, patient safety officer, a community member and a member of the infection control team. All of the above personnel will be offered the opportunity to attend infection control meetings via phone or zoom meeting virtually if needed.
3.DON/designee will audit attendance sheets to ensure all required personnel are in attendance for two quarters then again on the third quarter to ensure compliance.
4.Findings will be summarized and reported to the Quality Assurance Performance Improvement Meeting. Quality Assurance Performance Committee will determine the need for further audits and/or recommendation until compliance is met.

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