Nursing Investigation Results -

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

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POTTSVILLE REHABILITATION AND NURSING CENTER
Inspection Results For:

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

Based on an Abbreviated Complaint Survey completed on November 30, 2021, it was determined that Pottsville Rehabilitation and Nursing was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations





 Plan of Correction:


483.80(b)(1)-(4)(c) REQUIREMENT Infection Preventionist Qualifications/Role: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.
§483.80(b) Infection preventionist
The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must:

§483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;

§483.80(b)(2) Be qualified by education, training, experience or certification;

§483.80(b)(3) Work at least part-time at the facility; and

§483.80(b)(4) Have completed specialized training in infection prevention and control.

§483.80 (c) IP participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.
Observations:

Based on review of the facility's infection control policy and staff interviews, it was determined that the facility did not have one or more individuals serving as the infection Preventionist (IP) responsible for the facility's infection prevention plan, during a time period that included an outbreak of COVID-19 in the facility.

Findings included:

Interview with the facility's Director of Nursing (DON) during entrance conference on November 30, 2021, at approximately 9:35 AM revealed that the facility has a current outbreak of COVID-19 among its residents and staff. The DON stated that at the time of the survey ending November 30, 2021, the facility did not have an individual staff member qualified as the Infection Preventionist. The DON explained that presently the duties of the IP were being shared between herself (DON), and Employee 1 (Registered Nurse, Unit Manager).

A review of the facility policy entitled "Infection Prevention and Control Program (IPCP)", policy review date June 1, 2021, indicated that the facility will identify a staff member to be responsible for implementation of the infection prevention and control program, this person will be the infection Preventionist (IP). The facility assures that there is an infection control program that is effective for investigation, controlling and preventing infections. The infection control program includes the collection of data, monitoring and analyzing data. This data will be submitted to the monthly Quality Assurance and Performance Improvement (QAPI) committee. When a resident develops a reportable disease, the facility will report the information to the appropriate health agencies and Long - Term Care agencies.

There was no documented evidence at the time of the survey, November 30, 2021, that resident health care associated infections that met the ACT-52 state reporting requirements were current and or reported to the state survey agency.

Interview with Employee 1 (RN), on November 30, 2021 at approximately 11:30 AM, stated that she is not qualified as an Infection Preventionist (IP) and confirmed that the facility has a current outbreak of COVID-19 among its residents and staff.

A further interview with the Employee 1 (RN), on November 30, 2021 at approximately 1:30 PM, confirmed that the facility's COVID-19 testing logs were not accurately completed and/or maintained/monitored to demonstrate compliance with COVID testing requirements during the time that the facility was without a qualified (IP).

Interview with the Director of Nursing (DON), on November 30, 2021 at approximately 1:50 PM, revealed the Infection Preventionist resigned on October 7, 2021 and that the facility has not yet filled this position since that time. However, did indicate that the facility had hired an individual to fulfill this position, but 3 days into the facility orientation, had resigned on November 4, 2021. The DON stated that neither she nor any other facility staff member currently held the required IP credentials.

Interview with the Nursing Home Administrator (NHA) on November 30, 2021 at approximately 9:41 AM confirmed the facility does not currently have an Infection Preventionist performing the regulatory required duties.

Refer F 886

28 Pa. Code 201.14 (a) Responsibility of licensee

28 Pa. Code 201.18 (e)(1)(3)(6) Management

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

28 Pa. Code 211.10(a)(d) Resident care policies







 Plan of Correction - To be completed: 12/21/2021

1. The facility has a qualified Infection Preventionist. The facility cannot retroactively report infections that met the ACT 52 state reporting requirements. The facility cannot retroactively correct the facility's COVID-19 testing logs.

2. A facility audit for the timeframe of December 1st to present will be completed to ensure infections that met the ACT-52 state reporting requirements were reported. Any infections meeting the reportable requirements will be reported. A facility audit from December 1st to present will be completed to ensure Covid-19 testing logs are accurate and up to date.


3. The Regional Nurse will educate the NHA/DON and Infection Preventionist on Act-52 state reporting requirements for infection. The education will include maintaining COVID-19 testing logs for staff and residents during outbreak/surveillance testing.

4. The DON/IP will complete weekly audits x 4 and monthly x 3 to ensure infections meeting the Act-52 state reporting requirements are reported. The DON/designee will complete weekly audits x 4, then monthly x 3 to ensure Covid-19 tracking logs are completed for staff and residents during outbreak/surveillance testing. The results of the audits will be reviewed at the monthly QAPI meeting.

5. Date of compliance is 12/21/21.
483.80 (h)(1)-(6) REQUIREMENT COVID-19 Testing-Residents & Staff: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 (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
limited to:
(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.
Observations:

Based on a review of select facility policy, testing protocols and logs and CMS directives and staff interviews it was determined that the facility failed to conduct required COVID-19 testing of staff and maintain accurate and complete staff COVID testing.

Findings included:

The facility policy entitled "COVID - 19 Guidance" effective February 23, 2021, indicated that testing of nursing home staff includes employees, consultants, contractors, volunteers and caregivers who provide care and services to residents on behalf of the facility. Upon newly identified COVID - 19 positive staff or resident in a facility that is unable to identify close contacts that all staff, vaccinated and unvaccinated, facility wide be tested.

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, an outbreak is defined as any new case that arises in facility. In response to the outbreak the facility must test all staff that previously tested negative until no new cases are identified and test all residents that previously tested negative until no new cases are identified. For outbreak testing, all staff and residents should be tested, and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. For individuals who test positive for COVID-19, repeat testing is not recommended. In keeping with current CDC recommendations staff and residents who have recovered from COVID-19 and are asymptomatic do not need to be retested for COVID-19 within 3 months after symptom onset.

QSO-Memo- 20-38-NH further states that documentation of testing includes the following: for symptomatic residents and staff, document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results. Upon identification of a new COVID-19 case in the facility, document the date the case was identified, the date that other residents and staff are tested, the dates that staff and residents who tested negative are retested, and the results of all tests. For staff routine testing, document the facility's level of community transmission, the corresponding testing frequency indicated and the date each level of community transmission was collected. Also, document the date(s) that testing was performed for unvaccinated staff, and the results of each test.

Interview with the facility's Director of Nursing (DON) during entrance conference on November 30, 2021, at approximately 9:35 AM revealed that the facility had a current outbreak of COVID-19 among its residents and staff.

Interview with the Employee 1 (RN), on November 30, 2021 at approximately 11:30 AM, confirmed that the facility has a current outbreak of COVID 19 among its residents and or staff.

A review of a three (3) month time period (September 2021 - November 2021) testing logs revealed that the facility required outbreak testing during September 2021, October 2021 and November 2021.

A review of facility provided documentation entitled "daily attendance report" indicated that Employee 2 (Nursing Assistant - NA) worked on September 28, October 1, and 5th, 2021, and Employee 3 (Licensed Practical Nurse - LPN) had worked October 23, 24, and 25th, 2021, and November 7, 2021.

A review of the facility's COVID-19 outbreak testing logs for September 2021, October 2021, and November 2021, revealed a list of all staff tested and revealed that both Employee 2 (NA) and Employee 3 (LPN) were not tested during those months.

Interview with Employee 1 (RN), on November 30, 2021 at approximately 1:30 PM, revealed that she was not familiar with either Employee 2 (NA) nor Employee 3 (LPN) because they were agency staff. However, Employee 1 verified that these employees should have been tested. Employee confirmed that the facility's COVID-19 testing logs were not accurately maintained to demonstrate compliance with COVID testing requirements during the time that the facility was in outbreak testing.

During an interview with the Director of Nursing (DON), on November 30, 2021 at approximately 1:50 PM, it was confirmed that the facility required outbreak testing of COVID 19 in September 2021, October 2021 and November 2021. She acknowledged that both Employee 2 (NA) and Employee 3 (LPN) were not tested as required. The DON also confirmed that the facility's COVID-19 testing logs were not accurately maintained to demonstrate compliance with COVID testing requirements during the time that the facility was in outbreak testing.



28 Pa. Code: 201.14(a) Responsibility of licensee.

28 Pa. Code: 211.12 (c) Nursing services.

28 Pa. Code 211.12(a)(d) Resident care policies



 Plan of Correction - To be completed: 12/21/2021

1. The facility cannot retroactively correct the lack of accurate logs to track COVID-19 testing of Employees 2 & 3.

2. To identify staff with the potential to be affected the DON/designee completed an audit of current staff to ensure accuracy of logs for COVID-19 testing.

3. The Regional Nurse provided education to the Infection Preventionist and Department Heads on the completion of the COVID-19 testing logs for residents and staff accurately.

4. The DON/designee will monitor the COVID-19 testing log for the staff weekly x 4 then monthly x 3 to ensure accuracy. The results of the audits will be reviewed at the monthly QAPI meeting.

5. Date of compliance is 12/21/21.
§ 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 review of select facility policies and staff interviews it was determined that the facility was not in compliance with the requirements of 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 which meets on a facility scheduled basis (quarterly is recommended) and written notification to any resident who acquired a health care-associated infection at the facility.
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.

Act 52 indicates the facility members should meet to determine if the established infection control plan is effective. Act 52 indicates to review committee meeting minutes/attendance sheets should be reviewed to check for mandatory members and meeting schedule.

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.

There was no documented evidence at the time of the survey, November 30, 2021, that resident health care associated infections that met the ACT-52 state reporting requirements were current and or reported to the state survey agency.

Interview with Employee 1 (RN), on November 30, 2021 at approximately 11:30 AM, stated that she is not qualified as an Infection Preventionist (IP), and is unable to report the information (reportable disease), to the appropriate health care associated infections that met the ACT-52 state reporting because she does not have access to the system(s).

Interview with the Director of Nursing (DON), on November 30, 2021 at approximately 1:50 PM, revealed that she had been working in the facility since August 2021. The DON indicated she is unable to report the information (reportable disease), to the appropriate health care associated infections that met the ACT-52 state reporting because she does not have access to the system(s). She further stated that the Infection Preventionist resigned on October 7, 2021 and that the facility had not filled this position since that time. The DON verified that facility was not in compliance with ACT 52 requirements.





 Plan of Correction - To be completed: 12/21/2021

1. The facility cannot retroactively correct that the facility did not have an Infection Control Committee to meet the Act 52 Infection Control Plan. The facility cannot retroactively report infections that met the Act-52 state reporting requirements.

2. An Infection Control Committee has been formed and a meeting will be held. The Infection Control Committee will meet quarterly. A facility audit for the timeframe December 1st to present will be completed to ensure infections that met the Act-52 state reporting requirements were reported. Any infections meeting the reportable requirement will be reported.

3. The Regional Nurse will educate the IP and Department Heads on the need to have an Infection Control Committee and the need to meet quarterly. The Regional Nurse will educate the NHA/DON and Infection Preventionist on the Act-52 state reporting requirements for infections.

4. The DON/IP will complete weekly audits x 4 and monthly x 3 to ensure infections meeting the Act-52 state reporting requirements are reported. The results of the audits will be reviewed at the monthly QAPI meeting. Infections meeting the Act-52 reporting requirements will be reviewed at the quarterly Infection Control Committee Meeting.

5. Date of Compliance is: 12/21/21



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