Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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SOUTHMONT OF PRESBYTERIAN SENIORCARE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
A COVID-19 Focused Emergency Preparedness Survey was conducted by The Department of Health (DOH) on February 19, 2021. Southmont of Presbyterian Seniorcare was in compliance with 42 CFR 483.73 related to E-0024(b)(6).

 Plan of Correction:

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance Survey, and COVID19 Focus Infection Control Survey completed on February 19, 2021, it was determined that Southmont of Presbyterian Seniorcare, was not in compliance with the 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:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Based on observations and staff interviews, it was determined that the facility failed to properly label, date and seal food products in the main kitchen risking the potential of food borne illnesses

Findings include:

During an observation in the main kitchen on 2/16/21, at 9:25 a.m. the following was observed:

Dry storage area:
1 bag of tortilla shells was not labeled and dated.
1 large opened bag of granola was not labeled and dated.
2 bags of tortilla chips were not labeled and dated.

Walk in cooler #3:
1 pack of 6 hot dog buns was not labeled and dated.

Walk in freezer located inside of walk in cooler #3:
1 large opened bag of fish filets was not labeled, dated, and sealed.
1 opened bag of round breaded patties was not labeled and dated.

Bread Shelves:
1 loosely wrapped croissant roll was not labeled, dated, and sealed.

Basement walk in freezer:
1 opened bag of chocolate chip cookie dough rounds was not labeled and dated.

During an interview on 2/16/21, at 10:00 a.m. the Registered Dietitian Employee E1 confirmed the facility failed to make certain food items were stored correctly to prevent the potential for food borne illnesses and cross contamination in the dry pantry area, bread shelves, walk in cooler and walk in freezers in the main kitchen of the facility.

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

28 Pa. Code: 201.18(b)(1) Management.

28 Pa. Code: 211,6(c) Dietary services.

 Plan of Correction - To be completed: 03/29/2021

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or the findings/conclusions set forth in the statement of deficiencies. The plan of correction has been prepared and/or executed solely because it is required by the provisions of Federal and State law.

1.Immediate action(s) taken for the resident(s) found to have been affected include:
The following items were immediately discarded, in the presence of the surveyor, during the walk through with Department of Health: tortilla shells, granola, two bags of tortilla chips, hot dog buns, breaded patties, croissants, cookie dough.
Upon detailed further investigation it was confirmed the fish fillets were delivered the day before Monday February 15, 2021 according to the sticker on the product, and we used that as the open date for the corrective action. The delivery was confirmed with USFoods invoice 2450865.
Staff members involved were promptly in-serviced on proper label, dating, and storage of food products.

2.Identification of other residents having the potential to be affected was accomplished by:
The facility has determined that all residents who consume food by mouth have the potential to be affected.

3.Actions taken/systems put into place to reduce the risk of future occurrence include:
Dietary staff have been educated by the Director of Dining Services on the facility's policies and practice guidelines for labeling, dating, and food storage. In-service training included instructing the staff on the proper way to label and date using the food storage label. The training also included properly sealing all food products.

4.How the corrective action(s) will be monitored to ensure the practice will not recur:
The Dietary Manager/designee will complete daily audits times two weeks followed by weekly audits times two months, of proper food storage in the dry storage area, coolers, and freezers to ensure that it is in accordance with the facility policy.

Findings of this audit will be discussed with the Resident Council members.

In addition, this issue will be brought to the Quality Assurance and Performance Improvement Committee for follow up and recommendations and tracked until the team determines substantial compliance has been achieved and maintained.
201.22(j) LICENSURE Prevention, control and surveillance of TB.:State only Deficiency.
(j) New employes shall have the 2-step intradermal skin test before beginning employment unless there is documentation of a previous positive skin reaction. Test results shall be made available prior to assumption of job responsibilities. CDC guidelines shall be followed with regard to repeat periodic testing of all employes.
Based on a review of facility policies, facility waiver, record reviews and staff interviews, it was determined that the facility failed to administer the Centers for Disease Control (CDC), United States, recommended 2 step intradermal tuberculin skin test for 4 of 5 new hire employees, (Employees E4, E5, E6, E7).

A review of the facility's policy, Human Resources Pre-employment Screening dated 12/14/16, section IV (B)(c) indicates the facility will follow the CDC's recommended guidelines for TB testing using either the Two Step Skin Test or the QuantiFERON Gold blood draw.

A review of the facility's policy, the Pennsylvania Department of Health granted the facility a permanent exception on 8/31/15, allowing the facility to use the QuantiFERON-TB Gold blood test as the approved method for testing for TB.

A review of 5 staff records on 2/19/21, revealed 4 of the 5 staff records reviewed indicated the facility used T-Spot testing as the method for screening new hires for tuberculosis.
Dining Services Aide Employee E4 received a T-Spot test on 12/14/20.
CNA Employee E5 received a T- Spot test on 12/16/20.
Environmental Services Aide Employee E6 received a T-Spot test on 1/28/21.
CNA Employee E7 received a T-Spot test on 1/26/21.

During an interview on 2/19/21, at 2:45 p.m., the Director of Nursing confirmed the use of T-Spot testing for screening new hires for tuberculosis, potentially risking resident health with a contagious airborne disease.

 Plan of Correction - To be completed: 03/29/2021

Upon notification of this issue, Washington Health System Occupational Medicine, who is contracted by the facility to complete pre-employment physicals, was notified by the facility to cease utilization of the T-Spot for employees from this location and that the QuantiFeron-TB Gold test must be utilized.
The facility has determined that no residents were found to have been put at risk for a contagious airborne disease as employees were tested through the T-Spot test, which is a comparable IGRA blood test for tuberculosis, and determined to be negative by Washington Health System's Occupational Medicine. No employees were found to have not been screened for tuberculosis. The facility understands that the T-Spot test falls outside of the existing/approved waiver and is implementing the plan of correction accordingly as follows.

The facility has drafted a new request to the Pennsylvania Department of Health for a waiver that includes the T-Spot as an acceptable replacement for tuberculosis screening. Moving forward and in the meantime, new candidates entering the pre-employment process will be screened using the existing waiver for QuantiFeron-TB Gold or the approved Two Step Skin Test until such a time a decision is made on the waiver that would approve the change to T-Spot utilization.

Hiring managers and Human Resources staff will be educated by the Nursing Home Administrator on 201.22(j) Licensure, Prevention, control, and surveillance of TB as well as the components of 0630.

Audits of new employee files will be completed by the Human Resources Director/designee weekly times two months and monthly times two months to ensure compliance with 201.22 (j) and the components of 0630.

Results of the findings will be brought to the Quality Assurance and Performance Improvement Committee for follow up and recommendations and tracked until the team determines substantial compliance has been achieved and maintained.

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