(a) When a resident develops a reportable disease, the administrator shall report the information to the appropriate health agencies and appropriate Division of Nursing Care Facilities field office. Reportable diseases, infections and conditions are listed in § 27.21a (relating to reporting of cases by health care practitioners and health care facilities).
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Observations:
Based on review of facility policy; clinical record review; facility infection control notifications to the state pertaining to reportable diseases, infections, and conditions (which included lice); and staff interview, it was determined that the facility failed to report three instances of lice to the Division of Nursing Care Facilities field office for two of two residents reviewed (Residents 1 and 2).
Findings include:
Review of facility policy, titled Infection Control Policies and Procedures, last reviewed May 1, 2025, read, in part, centers will report all communicable diseases according to state, city, and county health regulations.
Review of facility submitted infection control reports to the Pennsylvania Department of Health, Division of Nursing Care Facilities, revealed there were no reports submitted pertaining to lice in the past three months.
Review of Resident 1's clinical record documented diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), auditory hallucinations, and cognitive communication deficit (impairment in communication that stems from underlying disorders cognitive process).
Further review of Resident 1's clinical record documented she was observed to have lice on December 28, 2025, and treatments were administered on December 29th, 2025, and January 8, 2026. Lice were again observed in her hair on February 5, 2026, and treated February 6th and 12th, 2026. Then Resident 2, her roommate, was observed to have lice on February 25th, 2026, and Resident 1 was prophylactically treated on February 26th, 2026, and ordered treatment on March 7th, 2026.
Review of Resident 2's clinical record documented diagnoses that included Alzheimer's disease (progressive brain disorder that slowly damages nerve cells, causing a gradual loss of memory, thinking and language abilities), dementia, anxiety (a feeling of worry, nervousness, or unease), aphasia (loss of the ability to understand or express speech), and encounter for palliative care.
Further review of Resident 2's clinical record documented she was observed to have lice on February 25, 2026, and was treated on February 26th, 2026, and ordered treatment on March 7th, 2026.
Both Residents were assessed and treated timely for lice.
Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on March 2, 2026, at 8:00 AM, revealed they were not aware that lice needed to be reported to the Pennsylvania Department of Health, Division of Nursing Care Facilities Field Office.
Additional interview with NHA and DON at 10:45 AM confirmed the lice infestations should've been reported.
| | Plan of Correction - To be completed: 03/09/2026
Event Report was missed due to updated requirements within the State Reporting Regulations.
No residents were found to have any adverse effects from the deficient practice.
A 3 month look back was conducted to ensure no other events of lice were unreported.
Administrator, Infection Control Preventionist (ICP) and Director of Nursing (DON) reviewed/educated on the State Tag and acknowledged the new/missed reporting requirements.
All reportable diseased will be reviewed weekly for the next four weeks, then monthly for the next two months to make sure reporting requirements are met. Results will be reviewed with QAPI. ICP will bring any infectious disease reporting changes to the QAPI committee to educate moving forward.
Date of Compliance: 3/9/2026
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