Pennsylvania Department of Health
SOUTHEASTERN PENNSYLVANIA VETERANS' CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SOUTHEASTERN PENNSYLVANIA VETERANS' CENTER
Inspection Results For:

There are 133 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


SOUTHEASTERN PENNSYLVANIA VETERANS' CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Findings of an Abbreviated Complaint Survey completed on March 16, 2024, at Southeastern Pennsylvania Veteran's Center, identified deficient practice, related to the reported complaint allegations, under 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 as they relate to the Health portion of the survey process.

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

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.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on clinical record review and staff interview, it was determined that Southeastern Pennsylvania Veterans' Center failed to ensure that one of 24 residents reviewed did not have an oncology consult timely (Resident R1).

Findings include:

Review of Resident R1's clnical record revealed the resident was admitted to the facility in November 2023 with a diagnosis of cancer.

Review of Resident R1's clinical record revealed Certified Registered Nurse Practitioner assessed the resident on November 2, 2023 with a notation of cancer as a diagnosis.

Review of Resident R1's clinical record revealed a liver biopsy was scheduled for January 31, 2024 and an oncology (physician that specializes in treatment of cancer disorders) appointment scheduled for February 23, 2024.

Review of Resident R1's clinical record failed to reveal any documented evidence that the resident's cancer was assessed by an oncologist or course of treatment identified.

Interview on March 14, 2024 at approximately 11:45 p.m. with the Director of Nursing, confirming the above information.

Pa 28 211.12(a)(c)(d)(3)(5) Nursing Services

Pa 28 211.5(f)(g)(h)Clinical Records

Plan of Correction - To be completed: 05/07/2024

Resident R1's course of treatment is up to date for cancer diagnosis.

Residents admitted since 8/1/2023 with a cancer diagnosis will be audited to ensure oncologist assessment was completed or course of treatment was identified.

Nurse Educator/designee will issue education to the current medical provider(s) on ensuring residents' cancer is assessed by an oncologist or course of treatment is identified upon admission.

Audit will be completed on new admissions with a cancer diagnosis to ensure assessment is completed by an oncologist or a course of treatment is identified 1x/week for 4 weeks then 2x/month for 3 months.

Results of the audits will be reviewed at the Quality Assurance &
Performance Improvement meetings to determine further actions as
necessary.

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