Nursing Investigation Results -

Pennsylvania Department of Health
BERWICK RETIREMENT VILLAGE NURSING HOME
Patient Care Inspection Results

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BERWICK RETIREMENT VILLAGE NURSING HOME
Inspection Results For:

There are  90 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.
BERWICK RETIREMENT VILLAGE NURSING HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance Survey completed on August 23, 2019, it was determined that Berwick Retirement Village Nursing Home 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(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 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.
483.10(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 a review of clinical records, resident interview and staff interview, it was determined that the facility failed to afford a resident the right to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) as evidenced by one resident out of 26 sampled. (Residents 106).

Findings include:

A review of the facility "Inpatient/ Outpatient Conditions of Admission and Consent to Medical Treatment" forms revealed that at the time of admission the resident is to review the Advance Directive Acknowledgment portion of the form and select the appropriate option that pertains to the resident. If the resident has executed an Advance Directive, they must make it known, and provide the facility with a copy for review and to be made part of the resident's medical record. The facility will provide the resident, family or representative with the advance directive information upon request if that option is selected.

A review of the clinical record revealed that Resident 106 was admitted to the facility on June 1, 2018, with diagnoses that included diabetes, dysphagia (difficulty swallowing) and muscle weakness.

A review of Resident 106's admission forms revealed that the selections in the Advance Directive Acknowledgment portion of the form were not completed.

A review of the resident's clinical record revealed that the resident was moderately cognitively impaired with a BIMS (brief interview for mental status - a tool to assess cognitive function) score of 12 (a score of 8-12 indicates moderate cognitive impairment).

Interview with Resident 106 on August 22, 2019, at approximately 9:30 a.m. revealed that the facility had not asked him about formulating an advanced directive or living will.

An interview with the Director of Nursing (DON) on August 23, 2019, at approximately 10:30 a.m. confirmed that Resident 106's admission form was not complete and that there was no evidence that he was offered the opportunity to develop an advanced directive.

28 Pa. Code 201.29 (a)(l)(2) Resident rights
Previously cited 4/10/19, 12/1/18

28 Pa. Code 211.5 (f) Clinical records.
Previously cited 9/28/19, 4/10/19, 12/1/18









 Plan of Correction - To be completed: 10/22/2019

1. Resident 106 Advanced Directive Form was completed by Social Service Director and reviewed with resident on August 29, 2019.
2. All current residents will have charts reviewed for Advanced Directives and completed and reviewed with resident/representative, if necessary.
3. Admissions Director will monitor that all new admissions will have Advance Directive prior to or day of admission and follow up with any that do not.
4. Admissions Director/Designee will audit new admission records for Advance Directives monthly x 3 months and report findings to QAPI or until achieve substantial compliance.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:
Based on a review of a clinical records and select facility policy and staff interviews, it was determined that the facility failed to implement established procedures for a thorough investigation of an injury of unknown origin sustained by one resident (Resident 99) out of two reviewed.

Findings include:

Review of the facility's current policy entitled "Incident/Accident Report" dated and last reviewed on August 14, 2019, revealed that regardless of how minor the Incident/Accident may be, including injuries of unknown origin, it must be reported to the charge nurse as soon as possible. Further review of the policy indicated that an "Incident/Accident Report" will be completed for all resident incident/accidents or injuries of unknown source and completed as soon s possible after the occurrence and no later than by the end of the shift on which it occurred. The policy also stipulated that "Witness Statements" will be obtained immediately from any individual witnessing the incident/accident and "Un-Witness Statements" will be obtained for a 72 hour period prior to injury of unknown origin - any staff member that had possible contact with the resident in a 72 hour period prior to the discovery of injury of unknown origin.

A review of the clinical record revealed that Resident 99 was admitted to the facility on November 4, 2018, and had diagnoses that included depression, difficulty walking, a history of falls, and a recent hypertension.

The resident's quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 6, 2019, indicated that the resident had a Brief Interview for Mental Status (BIMS - a tool to assess cognitive function) score of 12, which indicated moderate cognitive impairment. The MDS assessment also indicated the resident was dependent on staff for all activities of daily living (ADLS- the basic tasks of everyday life, such as bathing, dressing, toileting, walking, transferring and repositioning.

A nursing note dated July 27, 2019, at 7:24 p.m. revealed that the resident "complained of severe pain to left hip, assessed left hip, no bruising, bleeding, trauma or swelling noted. verbalizes sharp, burning pain that radiates to knee, call to MD. order to send to ER for evaluation. ER verbalized, resident admitted with diagnosis of left hip fracture. supervisor aware. resident is own responsible party."

An addendum to previous (nursing note) also dated July 27, 2019, at 7:27 p.m. revealed "resident has had no recent falls and verbalizes no trauma to left hip" with resident stating "I don't know it hurts, I haven't done anything to it."

During an interview with Resident 99 on August 21, 2019, at approximately 9:25 a.m. the resident stated she "did not do anything that could have caused the injury and didn't think staff had done anything but I don't know."

There was no documented evidence that the facility had thoroughly investigated the resident's injury of unknown origin. The facility did not initiate an "Incident/Accident Report" as a result of the resident's injury of unknown origin and was unable to provide evidence of a thorough investigation into the potential origin of the resident's serious injury to rule out abuse, neglect or mistreatment as a potential cause.

During an interview on August 22, 2019, at approximately 2:07 p.m., the Nursing Home Adminstrator and Director of Nursing confirmed that the facility failed to follow their policy with respect to initiating an Incident/Accident Report and conducting a thorough investigation into the resident's injury of unknown origin.




28 Pa. Code 201.14(a)(c) Responsibility of Licensee.
Previously cited 12/1/18, 9/28/18

28 Pa. Code 201.18(e)(1) Management.
Previously cited 12/1/18, 9/28/18

28 Pa. Code 201.29(a)(c) Resident Rights.
Previously cited 9/28/18,

28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services.
Previously cited 4/10/19, 12/1/18, 9/28/18

























 Plan of Correction - To be completed: 10/22/2019

1. Resident 99 has had no further incidents of unknown origin noted during medical record review on 9/4/2019 by Interdisciplinary Team.
2. Any incident reported to Supervisor will be investigated immediately by Supervisor, Interdisciplinary Team during the next IDT meeting.
3. Licensed staff will be in serviced on Incident/Accident Report Policy with focus on injuries of unknown origin and the required investigation process.
4. Unit Coordinators/RN Supervisors will audit 24 hour report to ensure there are no injuries of unknown origin that need investigation. Audits will be reviewed by Interdisciplinary Team during am meeting. Results of the audits will be present to QAPI monthly for 3 months or until the facility achieves substantial 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 the facility failed to ensure that a written notice of transfer to the hospital was provided to the resident and the residents' representative in a language and manner that could be understood for four out of 26 residents reviewed (Residents 91, 52, 53 and 59).

Findings include:

A review of the clinical record revealed that Resident 91 was transferred to the hospital on August 3, 2019, and returned to the facility on August 4, 2019. A review of the transfer notice provided to Resident 91's responsible party indicated that the resident was transferred to the hospital for "syncope."

A review of the clinical record revealed that Resident 52 was transferred to the hospital on August 3, 2019 and returned to the facility on August 4, 2019. A review of the transfer notice provided to Resident 52's responsible party indicated that the resident was transferred to the hospital for "fall with head trauma."

A review of the clinical record revealed that Resident 53 was transferred to the hospital on August 1, 2019, and returned to the facility on August 6, 2019. A review of the transfer notice provided to Resident 53's responsible party indicated that the resident was transferred to the hospital for GI bleed. The resident was also admitted to the hospital on August 9, 2019, and returned to the facility on August 10, 2019, A review of the transfer notice provided to Resident 53's responsible party indicated that the resident was transferred to the hospital for "low Hgb."

A review of the clinical record revealed that Resident 59 was transferred to the hospital on March 7, 2019 and returned to the facility on March 9, 2019. The facility was unable to provide evidence of the transfer notice provided to Resident 59's responsible party with the reason for the resident's transfer.

Interview with the Nursing Home Administrator on August 23, 2019, at 11:30 AM, confirmed that written notices provided to the resident and residents' representative did not note the reason for transfer in a language that could be easily understood.


483.15(c)(3) Notice before transfer
Previously cited 9/28/18

28 Pa. Code 201.29(h) Resident rights
Previously cited 9/28/18, 12/1/18, 4/10/19

28 Pa. Code 201.14(a) Responsibility of Licensee
Previously cited 9/28/18, 12/1/18















 Plan of Correction - To be completed: 10/22/2019

1. Residents 91,53,59,52 are currently in the facility and have had no transfers/discharges to hospital. Nurse management reviewed their most recent reasons they were transferred to the hospital, explaining any terms they did not understand.
2. Any discharge/transfer to the hospital paperwork will have the reason in language that is easily understood.
3. Social Service Director and Licensed Staff will be in serviced on using language that can be easily understood when completing the reason for discharge/transfer to the hospital.
4. Social Service Director will audit monthly x 3 months or until the facility achieves substantial compliance and report the findings to QAPI.

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 review of clinical records and staff interviews it was determined that the facility failed to develop a person-center comprehensive plan of care to meet the specific needs of three residents out of 26 sampled (Residents 2 and 66).

Findings include:

A review of the clinical record revealed that Resident 2 was admitted to the facility on May 2, 2019 and was identified to have frequent bladder incontinence.

A review of Resident 2's current comprehensive plan of care, conducted on August 21, 2019, revealed that the facility failed to include the specific individualized interventions planned to address the resident's frequent bladder incontinence.

A review of the clinical record revealed that Resident 66 was admitted to the facility on May 9, 2018, with diagnoses to include chronic kidney disease with dependence on kidney dialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood).

A review of Resident 66's current comprehensive plan of care initiated on May 22, 2018 and revised on by the facility on July 17, 2019 revealed that the facility failed to address emergency care of the resident's right upper chest dialysis access site.

A review of the clinical record revealed that Resident 91 was admitted to the facility on November 20, 2018, and at the time of the survey ending August 23, 2019, had current diagnoses that included hypertension, abnormalities of gait, muscle weakness, difficulty walking and falls.

Review of Resident 91's clinical record revealed that the resident fell on June 23, 2019 at approximately 5:30 a.m. in the resident's room.

Review of the incident investigation dated June 23, 2019 revealed that the facility planned to make sure the resident's room door is not closed and staff were to remind resident to not keep the room door closed.

Interview with the Director of Nursing on August 23, 2019, at approximately 9:35 a.m., confirmed that these care plan failed to address Resident 2's urinary incontinence and the potential for emergency care of Resident 66's dialysis access site. During an interview with the Director of Nursing (DON) on August 23, 2019, at approximately 11:35 a.m. the DON confirmed that the newly planned intervention to prevent future falls for Resident 91 after the resident's on June 23, 2019, was not added to the resident's plan of care to meet the resident's safety needs.




28 Pa. Code 211.11(d) Resident care plan.

28 Pa. Code 211.12 (c)(d)(3)(5) Nursing Services.
Previously cited 9/28/18, 12/1/18, 4/10/19










 Plan of Correction - To be completed: 10/22/2019

1. Resident 2's care plan has been reviewed and updated including individualized interventions for incontinence. Resident 66's care plan has been reviewed and updated including emergency care of the resident's right upper chest dialysis access site. Resident 91's care plan has been reviewed and updated including current fall interventions.
2. Current resident's care plans will be reviewed and updated by MDS Coordinators, Unit Coordinators and IDT to ensure information is accurate and current. Charge Nurse will update care plan with any new order or incident intervention.
3. Licenses staff will be in serviced on updating care plans as necessary.
4. Care Plans audits will be done at am meeting by IDT with review of any new orders or
incident interventions. DON will report findings of audits at QAPI monthly x 6 months or until we achieve substantial compliance.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on a review of clinical records and resident and staff interview, it was determined that the facility failed to demonstrate that one resident had been afforded the opportunity to participate in the development of the resident's plan of care out of 26 residents sampled (Resident 106)

Findings included:


A review of the clinical record revealed that Resident 106 was admitted to the facility on June 1, 2019, with diagnoses to include dysphagia (difficulty swallowing) and diabetes.

Interview with Resident 106 on August 22, 2019, at approximately 9:00 a.m. revealed that the resident stated that he was not invited to attend the most recent meeting to discuss his current plan of care.

Review of Resident 106's clinical record revealed that a letter, dated July 23, 2019, was sent to the resident's son regarding a plan of care meeting scheduled for August 6, 2019 at 2:00 p.m.

An Interdisciplinary note dated July 30, 2019, indicated that the team met on that date to review the resident's plan of care. Further review of the clinical record revealed no documentation that the either the resident or his son had attended the meeting held on July 30, 2019, which had been scheduled for August 6, 2019, according to the letter to the resident's son.

During an interview with the Director of Nursing (DON) on August 23, 2019, at approximately 11:35 a.m. confirmed that there was no evidence that Resident 106 had been invited to the most recent care plan meeting and/or afforded the opportunity to participate in the development/review of his current plan of care. .




28 Pa. Code: 211.11 (c)(d) Resident Care Plan

28 Pa. Code: 211.12 (c)(d)(1)(3)(5) Nursing Services
Previously cited: 9/28/18, 12/1/18, 4/10/19














 Plan of Correction - To be completed: 10/22/2019

1. Social Service Director met with Resident 106 and discussed the care plan meeting and his right to attend or decline.
2. Almost all residents who are not comatose and responsible parties will be invited to care plan meeting.
3. Process was developed for inviting and monitoring attendance of resident and families at care plan meetings.
4. Audits will by Social Service Director weekly x 3 months to ensure residents and families were invited to care plan meeting.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on clinical record review and observations it was determined that the facility failed to provide services necessary to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for one resident out of one resident reviewed (Residents 91).

Findings include:

Observation of Resident 91 on August 20, 2019 at approximately 10:00 a.m. and 12:40 p.m. revealed that dark brown debris observed beneath the resident's nails.

An additional observation of Resident 91 on August 21, 2019 at approximately 12:06 p.m. revealed dark brown debris was observed beneath the nails.

A review of the resident's quarterly Minimum Data Set (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) completed on June 3, 2019, revealed that the resident required extensive assistance from one person for grooming, personal hygiene and bathing.

The Director of Nursing Services (DON) confirmed during interview on August 23, 2019, at approximately 9:40 a.m. that the resident required assistance with grooming and personal hygiene. The DON confirmed that the resident's nails required cleaning and trimming.

Interview with the Nursing Home Administrator (NHA) on August 23, 2019, at approximately 9:50 a.m. confirmed the expectation that staff provide assistance with activities of daily living to Resident 91 to maintain good personal grooming.

28 Pa. Code 211.12 (a)(c)(1)(3)(5) Nursing services




 Plan of Correction - To be completed: 10/22/2019

1. Resident 91 allowed some of his nails to be cleaned and clipped. The Resident care plan was updated to reflect his refusal of nail care.
2. All Residents who allowed the facility had nail care done, residents who refused had their care plans updated to reflect this.
3. CNA staff will be reeducated on the facility policy on nail care.
4. Unit coordinator will audit nail care monthly x 3 months and report findings at QAPI or until substantial compliance is achieved.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on observation, clinical record review and staff interview, it was determined the facility failed to provide oxygen therapy as prescribed by the physician to meet the respiratory treatment needs of one of two residents sampled (Resident 84).

Findings include:

A review of the clinical record of Resident 84 revealed a current physician order dated June 15, 2018, for oxygen 1 liter per minute (l/pm) via nasal cannula (pronged tubing that delivers oxygen to the nose), as needed, for shortness of breath.

Observation of the resident on August 20, 2019, at approximately 9:30 a.m. revealed that the resident was receiving 2 liters of oxygen per minute.

Observation of Resident 84 on August 23, 2019, at approximately 10:30 a.m. revealed that the resident was receiving 2 liters of oxygen per minute.

According to the American Thoracic Society, oxygen is a medication that requires a prescription from a healthcare provider. The provider will prescribe your oxygen at a specific flow rate and a specific number of hours per day. It is very important that oxygen is used as prescribed. Using too little oxygen may put a strain on the heart and brain, causing heart failure, fatigue or memory loss. Using too much oxygen can also be a problem. For some patients, using too much oxygen can actually cause them to slow their breathing to dangerously low levels. It is important to wear oxygen as your provider ordered it. If the patient starts to experience headaches, confusion or increased sleepiness after using supplemental oxygen, the patient may be getting too much.

Review of Resident 84's medication administration record for August 2019, conducted on August 23, 2019, indicated that the resident had not received or needed supplemental oxygen for the month of August 2019, although the resident was observed receiving supplemental oxygen at 2 liters per minute on both August 20, 2019, and August 23, 2019.

Interview with Employee 1, Licensed Practical Nurse (LPN) on August 23, 2019 at 10:52 a.m. confirmed that the current physician's order was for 1 liter of oxygen per minute, as needed. Employee 1 also confirmed that when observed the resident was receiving oxygen at 2 liters per minute.

Interview with Employee 1, LPN further confirmed that there was no documentation on the resident's medication administration record during the month of August 2019 that the resident had been utilizing supplemental oxygen.

Interview with the Director of Nursing on August 23, 2019, at approximately 1:00 p.m. confirmed that the physician's order for supplemental oxygen therapy was not followed for this resident



28 Pa. Code 211.12 (a)(d)(1)(3)(5) Nursing services
Previously cited 9/28/18, 12/1/18, 2/5/19, 4/10/19









 Plan of Correction - To be completed: 10/22/2019

1. Resident 84's physician was notified to clarify oxygen order.
2. Residents receiving oxygen had their orders checked with their tanks to make sure they were accurate.
3. Licensed staff will be educated on the administration of oxygen. CNA staff will be educated on not to administer oxygen due to it being a medication. Nursing staff will also be educated on facilities Oxygen Policy.
4. Unit Coordinators will audit monthly to ensure accuracy x 3 months or until substantial compliance is achieved.

483.25(l) REQUIREMENT Dialysis:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on review of clinical records, observations, and staff interviews it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for one resident out of one sampled receiving hemodialysis (Resident 66).

Findings include:


A review of the clinical record revealed that Resident 66 was admitted to the facility on May 9, 2018 with diagnoses to include chronic kidney disease with dependence on kidney dialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). The resident had a right upper chest central line for dialysis access on Mondays, Wednesdays and Fridays.

A review of the resident's physician's orders for the month of August 2019 identified that the resident was to attend dialysis on Mondays, Wednesdays and Fridays

According to the National Kidney Foundation patients receiving hemodialysis should keep emergency care supplies on hand.

A review of the resident's current plan of care revealed no interventions to address emergency care of the resident's dialysis access site.

An observation of Resident 66's room on August 22, 2019 revealed that there were no emergency supplies readily available in the event of an emergency with the resident's right upper chest central line dialysis access site.

Interview with Employee 2, Licensed Practical Nurse (LPN) on August 22, 2019, at approximately 11:15 a.m. confirmed that emergency equipment for the resident's access site should be at the resident's bedside.

Interview with Director of Nursing, (DON) on August 22, 2019, at approximately 1:00 p.m. confirmed that there was no emergency supplies readily available at the resident's bedside and neither the resident's care plan nor current physician orders identified the interventions or orders to address a potential emergency with the access site.


28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services.
Previously cited 9/28/18, 12/1/18, 2/5/19, 4/10/19







 Plan of Correction - To be completed: 10/22/2019

1. Resident 66 had emergency supplies added to wheelchair and bedside. Care Plan was updated to reflect the addition of these supplies.
2. All dialysis residents will have emergency supplies added.
3. Licensed staff and CNA will be in serviced on emergency care for dialysis access sites and the supplies necessary.
4. Unit Coordinator will audit dialysis resident monthlyx3 to ensure supplies are available. Findings will be reported to QAPI until substantial compliance is achieved.

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 and staff interviews, it was determined that the facility failed to attempt gradual dose reductions of psychoactive medications for one of five residents reviewed (Resident 112).

Findings included:

A review of Resident 112's clinical record revealed that the resident was admitted to the facility on October 27, 2017, with diagnoses to include anxiety and Psychotic disorder.

Physician orders dated April 26, 2018, included Alprazolam (an antianxiety medication) 0.25 mg two times daily for anxiety.

A pharmacist recommendation to the physician dated August 7, 2018, requested the physician consider attempting a dose reduction of the Alprazolam 0.25 to one time a day.

The physician's response was to disagree with the recommendation stating "psychiatry unstable has only recently been improved with current drug regimen. GDR (gradual dose reduction) not indicated."

A pharmacist recommendation to the physician dated September 11, 2018, requested the physician consider attempting a dose reduction of the Alprazolam 0.25 to one time a day.

The physician's response was to disagree with the recommendation stating "chronic long term psychiatric problem and instability GDR not indicated benefits outweigh risks."

A review of the resident individual behavior tracking for the use of the Alprazolam 0.25 mg two time a day, from August 2018, through August 2019, revealed a total of eight days of documented episodes of anxiety exhibited by the resident.

The resident also had admission physician orders dated October 27, 2017, for Risperdal (an antipsychotic medication) 0.5 mg daily for Psychotic disorder.

A pharmacist recommendation to the physician dated April 9, 2019, requested the physician consider reducing the Risperdal to 0.25 mg daily.

The physician's response was to disagree with the recommendation stating "chronic psychiatric issues, complex present prior to admission, having emotional variability still present GDR not indicated at this time."

A review of the resident's individual behavior tracking for the use of the Risperdal 0.5 mg daily, from August 2018, through August 2019, revealed a total of three days of documented episodes of behaviors (aggressive behaviors).

During an interview with the Director of Nursing on August 23, 2019, at 9:30 AM, she confirmed there was no attempts of gradual dose reduction of the above psychoactive medications although the resident has experienced minimal episodes of targeted behavioral symptoms being treated with those drugs during the last year.


28 Pa. Code 211.12 (c)(d)(3)(5) Nursing Services
Previously cited 9/28/18, 12/1/18, 2/5/19, 4/10/19

28 Pa. Code 211.5 (f)(g)(h) Clinical records
Previously cited 9/28/18, 12/1/18, 4/10/19

28 Pa. Code 211.9(a) (1)(k) Pharmacy Services
Previously cited 9/28/18

28 Pa. Code 211.2(a) Physician services












 Plan of Correction - To be completed: 10/22/2019

1. Resident 112 physician will be notified for possible gradual dose reduction.
2. Monthly gradual dose reductions recommended by pharmacy will be reviewed by IDT for approval by physician. Prescribing physicians will be educated on time frame for signing GDRs and SSD will monitor for compliance.
3. Staff will be educated on psychoactive medications, gradual dose reductions and identifying resident behaviors and interventions.
4. Social Service Director will audit GDR recommendations from the pharmacist monthly to ensure they are reviewed and addressed timely. Audits will be done monthly for 6 months or until substantial compliance achieved with the result reported to QAPI.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to maintain an accurate and complete clinical record for one resident out of 26 residents sampled (Resident 66).

Findings include:

A review of the clinical record revealed that Resident 66 was admitted to the facility on May 9, 2018 with diagnoses to include chronic kidney disease with dependence on kidney dialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood).

A nurse progress note dated June 2, 2019, written at 11:14 p.m. revealed that the resident had presented with a large amount of green yellow foul-smelling vaginal drainage and had complained of burning.

A review of the next available nurse progress note dated June 3, 2019, written at 7:14 a.m. revealed that the resident experienced a reported episode of unresponsiveness, but was responsive when nurse assessed her. Further review of clinical documentation revealed that the resident required oxygen therapy due to complaints of shortness of breath at which time, the resident requested to go to the hospital.

Review of resident transfer notification revealed that Resident 66 was transferred to the hospital due to change in responsiveness.

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient ' s EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care:
Assessments
Clinical problems
Communications with other health care professionals regarding
the patient
Communication with and education of the patient, family, and the patient ' s designated support person and other third parties.

There was no nursing documentation in the resident's clinical record indicating a clinical nursing assessment of the resident's status and change in condition resulting in the resident's transfer to the hospital.

Interview with the Director of Nursing, (DON) on August 23, 2019, at approximately 1:00 p.m. confirmed that the nursing staff failed to assure an accurate and complete account of the resident's change in condition were documented and communicated to the physician and the hospital emergency room.





28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services
Previously cited 9/28/18, 12/1/18, 2/5/19, 4/10/19

28 Pa. Code 211.15 (f)(h) Clinical records
Previously cited 9/28/18, 12/1/18, 4/10/19









 Plan of Correction - To be completed: 10/22/2019

Resident 66 was assessed by Unit Coordinator and offered OB/GYN appointment.
2. Residents will be reviewed at am clinical meeting by Interdisciplinary Team FOR CHANGE OF CONDITION AND ADD TO ALERT CHARTING.
3. Licensed staff will be educated on identifying change in conditions and documentation of the changes.
4. Audits will be done in am meeting by DON/Designee to ensure any change of condition is added to alert charting. Audit findings will be reported to QAPI for 6 months or until substantial compliance is achieved.

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 review of clinical records and select facility policy and staff interview, it was determined that the facility failed to implement Pneumococcal vaccination procedures to ensure the effective implementation of the facility's immunization program for one of five residents reviewed (Resident 95).

Findings include:

Review of the facility Pneumococcal Vaccine Policy last reviewed by the facility August 14, 2019, indicated that all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Before receiving the pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the vaccine. Provision of such education shall be documented in the resident's clinical record. For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the resident's clinical record. Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's clinical record indicating the date of the refusal of the pneumococcal vaccination.

Review of Resident 95's clinical record revealed that there was no documented evidence in the resident's clinical record to show that the facility conducted a screening and determined the resident's eligibility to receive the Pneumococcal vaccination. There was no documented evidence of education provided to the resident and/or the resident's representative. There was no documented evidence of a signed consent or refusal for immunization.

Interview with the director of nursing on August 23, 2019, at approximately 12:30 PM failed to provide documented evidence that the Pneumococcal Vaccination program was effectively implemented as per facility policy to ensure screening, eligibility, education and tracking of vaccination for Resident 95.

483.80 Infection Control
Previously cited 9/28/18

28 Pa Code 211.5 (f)(h) Clinical records
Previously cited 9/28/18

28 Pa Code 211.10 (a)(c)(d) Resident care policies
Previously cited 9/28/18

28 Pa code 211.12 (a)(c)(d)(1)(5) nursing services
Previously cited 9/28/18, 12/1/18, 4/10/19

28 Pa code 201.29 (a) Resident rights
Previously cited 9/28/18, 12/1/18, 4/10/19







 Plan of Correction - To be completed: 10/22/2019

Resident 1 was given Pneumococcal Vaccination.
2. Current resident's Pneumococcal Vaccination will be audited to determine if any other resident has requested it. If so it will be given.
3. MDS Coordinators will notify nursing if any resident has had Pneumococcal Vaccination after reviewing hospital paperwork. Licenses staff will be educated on Influenza/ Pneumococcal Vaccination Policy.
4. Unit Coordinators will audit Influenzas and Pneumococcal Vaccinations monthly and report the findings to QAPI. Audits will continue until substantial compliance is achieved.

201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:

Based on staff interviews and select facility policy review, it was determined that the facility did not comply with the requirements of the Act 52 Infection control plan.

Findings include:

Act 52 Infection Control Plan, states that a health care facility should develop and implement an internal infection control plan that should be established for the purpose of improving the health and safety of residents and health care workers and should include a multidisciplinary committee.

The multidisciplinary committee to include:

(i) Medical staff that could include the chief medical officer or the nursing home medical director
(ii) Administration representatives that could include the chief executive officer, the chief financial officer, or the nursing home administrator
(iii) Laboratory personnel
(iv) Nursing staff that could include a director of nursing or a nursing supervisor
(v) Pharmacy staff that could include the chief of pharmacy
(vi) Physical plant personnel
(vii) A plant safety officer
(viii) Members of the infection control team, which could include an epidemiologist
(ix) The community, except that those representatives may not be an agent, employee or contractor of the health care facility.

In addition, the Act requires effective measures for the detection, control and prevention of health care-associated infections, culture surveillance processes and policies, procedures and protocols for staff who may have potential exposure to a resident known to be colonized or infected with MRSA (methicillin resistant staph aureus, a bacteria resistant to many antibiotics) or MDRO ( multi-drug resistant organisms, which are common bacteria (germs) that have developed resistance to multiple types of antibiotics), An outreach process for notifying a receiving health care facility of any resident known to be colonized prior to transfer to another facility, a required infection-control intervention protocol, the procedure for distribution of advisories issued under section 405(b)(4) to staff in the facility, notification to facility staff of the infection control plan, documentation of the facility infection control reporting to PA-PSRS and written reports, documentation of notification of the serious event(infection) to the resident or responsible party.

Interview on August 23, 2019, at 12:30 PM, the Director of Nursing confirmed that the facility was not presently meeting the requirements of Act 52.





 Plan of Correction - To be completed: 10/22/2019

1. There were no residents directly affected by this.
2. Any resident meeting protocol will be reported on the PASRS site accordingly.
3. ADON will be enrolled in IP program and be responsible for Act 52.
4. ADON will audit infections to ensure we are compliant with reporting monthly for 6 months and report findings to QAPI.

209.8(b) LICENSURE Fire Drills.:State only Deficiency.
(b) A written report shall be maintained of each fire drill which includes date, time required for evacuation or relocation, number of residents evacuated or moved to another location and number of personnel participating in a fire drill.
Observations:

Based on a review of the facility's fire drill records and an interview with staff, it was determined that the facility consistently failed, in their written report, to include the time required for resident evacuation or relocation, and the number of residents evacuated or moved to another location.

Findings include:

A review of the facility's fire drill reports provided by the facility on August 22, 2019, and interview with the administrator at approximately 12:55 p.m., on August 22, 2019, revealed that the reports of the fire drills the facility conducted in the last year failed to consistenly contain written documentation that included the number of residents evacuated or moved to another location.



 Plan of Correction - To be completed: 10/22/2019

There were no residents specifically affected by this.
2. In service will be conducted by Director of facilities for current residents to acquaint them with our fire drill process.
3. Facilities Director will in service staff on fire drill procedures. Facilities staff will be in serviced on how to conduct a fire drill and documentation required.
4. Audits will be conducted by the Facilities Director for 6 months and present to QAPI to ensure documentation is complete.

211.5(d) LICENSURE Clinical records.:State only Deficiency.
(d) Records of discharged residents shall be completed within 30 days of discharge. Clinical information pertaining to a resident's stay shall be centralized in the resident's record.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to close clinical records within 30 days of discharge for one of three closed records reviewed (Resident 135).

Findings include:

A review of the clinical record of Resident 135 revealed that the resident was admitted to the facility on June 20, 2018 and expired at the facility on July 17, 2019. A physician's discharge summary was not completed until August 21, 2019.

Interview with the Director of Nursing on August 23, 2019, at approximately 11:37 a.m. confirmed that the physician's discharge summary was not completed within the 30 days.






 Plan of Correction - To be completed: 10/22/2019

1. Resident's d/c summary was completed late by the physician.
2. All discharge records over the past 30 days will be reviewed to ensure D/C summary is completed and timely. Physicians will be notified as indicated.
3. D/C residents will have d/c summary completed within 30 days by physician. Admission Director will in service physicians on the necessity of signing d/c summaries within 30 days.
4. Admission Director will audit discharge residents charts for timely signatures and report finding to QAPI monthly.


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