Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

There are  39 surveys for this facility. Please select a date to view the survey results.

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HOMEWOOD AT PLUM CREEK - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid, State Licensure, Civil Rights, and Complaint survey which ended on March 25, 2021, it was determined that The Homewood at Plum Creek 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:

483.20(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.
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for 1 of 22 residents reviewed (Resident 44).
of Resident 44's clinical record revealed diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder) and muscle wasting and atrophy (decrease indue to lack of physical activity)

Review of Resident 44's significant change MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated August 13, 2020 revealed in Section O0100 k. Hospice Care was not marked to indicate that Resident 44 was receiving Hospice care while a resident of this facility and within the last 14 days.

Review of Resident 44's Hospice discharge summary revealed that Resident 44 was receiving Hospice services starting August 15, 2019 until the time she was discharged from Hospice services on August 7, 2020 (6 days prior to the MDS being completed).
with the Director of Nursing on March 25, 2021 at 9:03 AM revealed that Resident 44 had been receiving Hospice services during the specified look back period for the MDS and should have been assessed accordingly. She also revealed that the MDS had been corrected when made aware of the inconsistency.

28 Pa. Code 211.5(f) Clinical records.
Pa Code 211.12 (d)(3)(5) Nursing Services.

 Plan of Correction - To be completed: 05/09/2021

"Preparation and evaluation of the enclosed plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provision of Federal and State law.

1. Resident #44's MDS was modified on 3/24/21 and submission sent 3/29/21 hospice services were captured to reflect an accurate assessment.

2. On 3/30/21 All MDS's completed for a resident receiving hospice services were audited to ensure that the MDS coding was accurate in the hospice care section 0100k. No other residents receiving hospice services at this time. No concerns were identified.

3. Education provided to the MDS team by the DON to accurately code any hospice services done within the 14 day look back period on the MDS section 0100k even if hospice services were discontinued.

4. Audits will be done by the RNAC on any resident receiving hospice services to ensure the resident's assessments are accurately reflected in the MDS. Audits will be done bi-weekly X 2 then monthly X 3 months in coordination with the resident's MDS schedule.
DON will review all hospice services (discontinued and initiated) at monthly care team meetings to inform MDS team of current residents receiving hospice care.

Corrective action will be completed by 5/9/21

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