|§483.80 (h) COVID-19 Testing. The LTC facility must test residents and facility staff, including|
individuals providing services under arrangement and volunteers, for COVID-19. At a minimum,
for all residents and facility staff, including individuals providing services under arrangement
and volunteers, the LTC facility must:
§483.80 (h)((1) Conduct testing based on parameters set forth by the Secretary, including but not
(i) Testing frequency;
(ii) The identification of any individual specified in this paragraph diagnosed with
COVID-19 in the facility;
(iii) The identification of any individual specified in this paragraph with symptoms
consistent with COVID-19 or with known or suspected exposure to COVID-19;
(iv) The criteria for conducting testing of asymptomatic individuals specified in this
paragraph, such as the positivity rate of COVID-19 in a county;
(v) The response time for test results; and
(vi) Other factors specified by the Secretary that help identify and prevent the
transmission of COVID-19.
§483.80 (h)((2) Conduct testing in a manner that is consistent with current standards of practice for
conducting COVID-19 tests;
§483.80 (h)((3) For each instance of testing:
(i) Document that testing was completed and the results of each staff test; and
(ii) Document in the resident records that testing was offered, completed (as appropriate
to the resident’s testing status), and the results of each test.
§483.80 (h)((4) Upon the identification of an individual specified in this paragraph with symptoms
consistent with COVID-19, or who tests positive for COVID-19, take actions to prevent the
transmission of COVID-19.
§483.80 (h)((5) Have procedures for addressing residents and staff, including individuals providing
services under arrangement and volunteers, who refuse testing or are unable to be tested.
§483.80 (h)((6) When necessary, such as in emergencies due to testing supply shortages, contact state
and local health departments to assist in testing efforts, such as obtaining testing supplies or
processing test results.
Based on a review of the facility's COVID-19 testing, standards established by the Centers for Medicare & Medicaid Services, and staff interview, it was determined the facility failed to timely conduct testing of two residents exhibiting signs and symptoms of COVID-19 out of 10 sampled residents. (Resident CR2 and 5)
According to the Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Survey & Certification Group QSO-Memo - 20-38-NH initially dated August 26, 2020 and revised September 10, 2021, residents who have signs or symptoms of COVID-19, vaccinated, or not vaccinated, must be tested immediately. While test results are pending, residents with signs or symptoms should be placed on transmission-based precautions.
A review of Resident CR2's clinical record revealed that on October 26, 2021, at 1:37 PM, the resident was noted to have malaise (a general feeling of discomfort, illness, or uneasiness), congestion, and an oxygen level of 89 percent (normal is 90 to 100) on room air.
Further review of the resident's clinical record revealed on October 26, 2021, at 2:05 PM, the resident was noted to be pale, warm to the touch, lethargic (sluggish), and congested.
A review of Resident 5's clinical record revealed on November 29, 2021, at 10:37 PM, the resident was noted to have a cough and oxygen level of 88 percent on room air.
Further review of the resident's clinical record revealed on November 30, 2021, at 12:58 PM, the resident was noted to have increased respirations and oxygen level of 86 percent of 2 liters of oxygen.
There was no documented evidence that the above residents were immediately tested for COVID-19 when the residents displayed symptoms and placed on transmission based precautions pending test results.
Interview with the Nursing Home Administrator on December 7, 2021, at approximately 2:00 PM confirmed that the residents were not tested immediately upon onset of potential symptoms of COVID-19.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 211.12 (c) Nursing services.
| ||Plan of Correction - To be completed: 01/18/2022|
Facility is unable to retroactively correct the past deficiency.
Residents records reviewed for signs or symptoms of COVID 19 and testing completed as needed.
Licensed staff re-educated on monitoring of residents for symptoms of COVID 19 and completing testing as indicated.
Resident documentation will be reviewed daily for any signs or symptoms of COVID 19 and will ensure testing was completed and transmission based precautions were implemented as needed and documented as indicated.
25% of resident records will be audited for any signs or symptoms of COVID 19 to ensure testing was completed as needed.
Results to QA for review and recommendations.