Nursing Investigation Results -

Pennsylvania Department of Health
CLIVEDEN NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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CLIVEDEN NURSING AND REHABILITATION CENTER
Inspection Results For:

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CLIVEDEN NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint, completed on 11/18/2019, it was determined that Cliveden Nursing and Rehabilitation Center 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 related to the health portion of the survey process.





 Plan of Correction:


483.70(p)(1)(2) REQUIREMENT Qualifications of Social Worker >120 Beds: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.
483.70(p) Social worker.
Any facility with more than 120 beds must employ a qualified social worker on a full-time basis. A qualified social worker is:

483.70(p)(1) An individual with a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling, and psychology; and

483.70(p)(2) One year of supervised social work experience in a health care setting working directly with individuals.
Observations:


Based on the review of clinical records, interviews with staff, review of personnel records and job description, it was determined that the facility failed to employ a qualified social worker on a full-time basis with a total bed capacity of 180 beds. This failure constituted substandard quality of care.

Findings include:

Review of the job description for the Social Services Director included the educational requirements which stated that a bachelor's degree in social work or human services field, and gerontology experience was required. Further review of the educational requirements for the Director of Social Services also indicated that the individual should have one year of supervised social work experience working directly with individuals in a health care setting.

Review of the personnel record for Employee E3 revealed that Employee E3 was hired by the facility on October 21, 2019 as the facility's Social Services Director. Further review of the personnel record for Employee E3 revealed that Employee E3 did not have a bachelor's degree in any field of study as required and stated in the Social Services Director's job description.

During interview with the Nursing Home Administrator on November 15, 2019 at approximately 3:18 p.m. the Nursing Home Administrator reported that Employee E3 had been working at the facility in the capacity of a social worker, and confirmed that Employee E3 did not have a bachelor's degree in any field of study. Further it was confirmed that the total facility resident census on November 19, 2019 was 170 residents. The facility total bed capacity is 180 skilled nursing beds.

During an interview with Employee E3 on November 19, 2019 at approximately 2:00 p.m. regarding the various tasks that she had been completing in her role as the Director of Social Services, Employee E3 stated that she was responsible for completing the initial social services assessments for new admission, the completion of care plans, the completion of residents Minimum Data Set (resident assessment of care needs) Section C- Cognitive status, Section D- Mood, and Section E- Behavior, discharge planning, which included, but not limited to holding discharge planning meeting with residents, making referrals for home health care agencies and making referrals for durable medical equipment. Employee E3 also stated that she was currently working with a couple of residents with transitioning from their current skilled nursing care facility to back to the community. Employee E3 also stated that she also held quarterly meetings with the care coordinators of residents who enrolled in certain insurance plans.

Review of the personnel record for Employee E4 revealed that Employee E4 was hired by the company that owns the facility on March 13, 2018, with the job title "Social Worker." Further review of Employee E5's personnel record revealed that Employee E5 did not have a bachelor's degree in social work, or any other human service field.
During a discussion with the Nursing Home Administrator on November 15, 2019 at approximately 2:20 p.m. the Administrator reported that Employee E4 worked for another facility that the company owned and that she had been coming over to the facility to assist in the social services department since October 4, 2019 for approximately 3-4 days a week to, and approximately 20 hours a week.

During an interview with the Nursing Home Administrator on November 19, 2019 at approximately 10:50 a.m. Employee E4's personnel file was reviewed, and it was discussed with the Nursing Home Administrator that Employee E4 does not have a bachelor's degree that meets the qualifications of a qualified social worker.

During an interview with Employee E4 on November 19, 2019 at approximately 2:44 p.m. regarding the various tasks that she had been completing in her role as social worker at the facility, Employee E4 reported that she completes sections Section C- Cognitive status, Section D- Mood, and Section E- Behavior of the Minimum Data Set assessment and that she completes an audit on the Physician's Order for Life Sustaining Treatment (POLST- a legal document stating the type of care a person would like in an emergency medical situation) and notifies Employee E3 of the residents who are still in need of one.

Review of Resident R1's POLST form revealed that that the POLST was completed by Employee E3.

Review of Resident R3's clinical record revealed that the Social Service Assessment was completed by Employee E4.

Review of Resident R6's clinical record revealed that the Social Service Assessment was completed by Employee E4.

Review of Resident R7's clinical record revealed an admission dated on November 8, 2019. The resident POLST and PASARR were completed by Employee E3.

Review of Resident R8's clinical record revealed Social Services notes were completed by Employee E3. Further review of the clinical record revealed that the Preadmission Screening and Resident Review (PASARR- federal requirement to ensure that a person with a mental disorder is not inappropriately placed in a skilled nursing facility) and the resident's care plan updated on October 30, 2019 were both completed by Employee E3.

Review of Resident R9's clinical record revealed that the resident was admitted to the facility on March 1, 2019. Review of the quarterly Minimum Data Set assessment completed on November 6, 2019 revealed that Sections C- Cognitive Status and D- Mood were completed by Employee E4. Review of the Social Service assessment dated November 6, 2019 revealed that the assessment was completed by Employee E4

The facility failed to employ a qualified social worker on a full-time basis resulting in Substandard Quality of Care.

Pa Code 211.16. Social Services

Pa Code 201.14 (a)Responsibility of licensee

Pa Code








 Plan of Correction - To be completed: 01/10/2020

Employee E3 is no longer the facilities Social Service Director. Employee E4 no longer assist the facility with work.

Facility employed a qualified social worker on a full time basis.

In order to protect residents from similar situation Administrator will review social workers education and work experience prior to hiring to an open position to ensure the candidate is qualified per the regulation.

Human Resources Regional/ Regional director or designee will audit new social worker hires quarterly x 4 then annually and report to NHA at QAPI to ensure ongoing compliance.

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