Pennsylvania Department of Health
WILLIAMSPORT HOME, THE
Patient Care Inspection Results

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WILLIAMSPORT HOME, THE
Inspection Results For:

There are  75 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.
WILLIAMSPORT HOME, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, Civil Rights Compliance Survey, and a Complaint Investigation completed on February 2, 2024, it was determined that The Williamsport Home 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 Regulation 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 affects more than a limited 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. This deficiency was not found to be throughout this facility.
§ 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, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered vital signs, interventions, and treatments for three of 24 residents reviewed (Residents 34, 76, and 99).

Findings include:

Clinical record review for Resident 34 revealed a current physician's order dated August 23, 2023, for staff to monitor their blood pressure and heart rate at 11:00 AM on Wednesdays and fax results to the physician if the heart rate was greater than 120 beats per minute (bpm) or less than 60 bpm and if the systolic blood pressure (pressure when the heart contracts) was greater than 160 mmHg (millimeters of Mercury) or less than 110 mmHg.

Review of Resident 34's clinical documentation revealed that staff completed blood pressures and heart rates on the following dates:

August 23, 2023, at 11:00 AM heart rate 56 bpm
November 15, 2023, at 11:00 AM blood pressure of 104/72 mmHg

Clinical record review for Resident 76 revealed a current physician's order dated May 15, 2023, for staff to monitor their blood sugar at 6:00 AM every Monday for diabetes mellitus type 2 (body's inability to regulate blood sugar levels) and notify the physician if it was greater than 220 mg/dL (milligrams/deciliter).

Review of Resident 76's clinical documentation revealed the following:

On January 8, 2024, at 6:00 AM, her blood sugar was 259 mg/dL.
On January 15, 2024, at 6:00 AM, her blood sugar was 237 mg/dL.
On January 22, 2024, at 6:00 AM, her blood sugar was 352 mg/dL.
On January 29, 2024, at 6:00 AM, her blood sugar was 244 mg/dL.

There was no documentation indicating that staff notified Resident 34's physician regarding her blood pressure and/or pulse or Resident 76's blood sugar levels being outside of the prescribed parameters prior to surveyor identification.

The surveyor reviewed the above information during an interview on February 2, 2023, at 8:15 AM with the Nursing Home Administrator.

Clinical record review for Resident 99 revealed the facility admitted her on September 23, 2023. Review of Resident 99's initial Bowel and Bladder Incontinence Assessment dated September 23, 2023, revealed Resident 99's daughter indicated she did not use incontinence products at home. The assessment further revealed Resident 99's daughter informed staff that Resident 99 has a bladder stimulator (a device that may help people with an overactive bladder or those unable to control their urge to urinate. The device can either go under the skin of the buttock or on the inside of the ankle) implanted in her right buttocks for a history of bladder retention. Resident 99's daughter revealed the bladder stimulator gets charged once a month. The restorative nurse signed off on Resident 99's assessment on October 8, 2023.

Further review of Resident 99's clinical record revealed the facility did not initiate a plan of care addressing Resident 99's bladder stimulator until November 20, 2023. The facility obtained a physician's order on November 21, 2023, to use a remote to check the bladder scanner weekly, if the color is green no charge is needed, if the color is orange, the bladder stimulator needs to be charged.

A physician's order dated November 21, 2023, revealed staff are to remove the bladder stimulator charger from the dock (light should be green), snap the charger onto the belt, hold the charger near the stimulator (upper right buttocks) and you will hear one long tone when the charger is over the stimulator, and tighten the belt. If you hear three beeps and feel the charger vibrate, you need to realign the charger with the stimulator, when you hear three sets of rising tones you are done charging.

Review of Resident 99's Treatment Administration Record (TAR, a form utilized to document resident nonmedication orders) dated November 2023 revealed the facility's first check of Resident 99's bladder stimulator was on November 21, 2023.

Interview with Employee 4 (licensed practical nurse) on February 1, 2023, at 10:55 AM revealed that she was not officially trained on Resident 99's bladder stimulator.

Interview with the Nursing Home Administrator, Director of Nursing, and Employee 1 (assistant director of nursing) on February 1, 2024, at 2:35 PM confirmed the findings for Resident 99's bladder stimulator.

Interview with Employee 1 on February 2, 2024, at 8:25 AM confirmed the restorative nurse was aware of Resident 99's bladder stimulator on her admission to the facility. Employee 1 could provide no further documentation that staff were educated and competent to utilize Resident 99's bladder stimulator.

483.25 Quality of Care
Previously cited 2/24/23

28 Pa. Code 211.10(c) Resident care policies

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


 Plan of Correction - To be completed: 03/25/2024

1. The physician for resident 34 was updated on the blood pressures and heart rates outside ordered parameters on 2/1/2024. The physician for resident 76 was updated regarding blood sugars outside ordered parameters on 2/1/2024. Resident 99 continues use of the bladder stimulation device with no issues.

2. An audit will be conducted to identify residents with physician orders indicating parameters for notification of blood pressure, heart rates or blood sugar outside prescribed ranges since January 1.

3. Re-education will be completed with licensed staff by DON or designee regarding physician notification for blood pressure, heart rates and blood sugar values outside physician ordered parameters as applicable. Education will be conducted by NHA to DON and Staff Development Coordinator regarding the need for proper training and competency for new resident products or devices to be utilized by staff. Staff Development Coordinator was informed of the need for education and competency for R99 bladder stimulation device and will complete with licensed staff members.

4. An audit of physician notification of values outside physician ordered parameters for residents identified in the full house audit will be conducted weekly x 3 and monthly x 2. Audit results will be reviewed by the Quality Assurance Performance Improvement Committee to determine resolution or need for continuation of audit process.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
§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.
Observations:

Based on observation and staff interview, it was determined that the facility failed to store food in a manner to prevent the potential spread of foodborne illness in the therapy suite and the facility's pantry for six of six nursing units (100, 200, 300, 400, 500 and Ravine Ridge Nursing Units).

Findings include:

Observation of the 100-nursing unit's pantry on February 1, 2023, at 8:24 AM revealed several items under the sink, including two containers of cleaning wipes, several glass vases, a lap blanket, two one-gallon containers of water, and a basin.

Observation of the 200-nursing unit's pantry on February 1, 2023, at 8:30 AM revealed several items under the sink, including several vases, a small trash can, a broken glass, and old Christmas decorations.

Observation of the Ravine Ridge nursing unit's pantry on February 1, 2023, at 8:34 AM revealed several items under the sink, including cleaning wipes, two containers of hand soap, a container of dish soap, vases, and a plastic piece for a refrigerator.

Observation of the Ravine Ridge nursing unit's satellite kitchen on February 1, 2023, at 8:37 AM revealed that there was a bag of chips with a use by date of October 6, 2020, in an upper cabinet.

Observation of the therapy's kitchen on February 1, 2024, at 8:47 AM revealed three bottles of Maraschino cherry juice with a best by date of September 25, 2022, in an upper cabinet; a bottle of apple juice in the fridge with a best by date of October 26, 2023; an unopened case of Italian ice pops with a best by date of March 2023; and a case and a half of single serving sherbet, chocolate, and vanilla cups that were dried out, separated, or had the paper lids popped off the top in the freezer. Under the sink there were refrigerator bins.

Observation of the second-floor pantry for the 300, 400, and 500-nursing units on February 1, 2023, at 9:03 AM revealed a refrigerator identified for resident use. There was no documentation that indicated staff were monitoring either the fridge or freezer temperatures. Neither the fridge or freezer thermometers were functioning and providing a reading at the time of the observation.

Concurrent interview with Employee 6, dietary manager, confirmed the observations.

This surveyor reviewed the above concerns with the Nursing Home Administrator during an interview on February 1, 2024, at 11:30 AM.

28 Pa. Code 201.14 (a) Responsibility of licensee


 Plan of Correction - To be completed: 03/25/2024

1. The items found during rounding were removed at the time of notification. A new temperature log will be placed on pantry refrigerators with an updated refrigerator and freezer temperature.

2. A full house audit of pantry areas and refrigerators will be conducted to ensure compliance. Any areas identified will be corrected.

3. Re-education to nursing assistants will be conducted by DON or designee regarding the expectation of staff to check pantry areas and temperatures. Re-education for department managers and staff will be completed by the NHA or designee that personal items are not to be placed in kitchenettes.

4. An audit of temperatures and kitchenettes will be conducted by Dining Services or designee weekly x 3 and monthly x 2. Audit results will be reviewed by the Quality Assurance Performance Improvement Committee to determine resolution or need for continuation of audit process.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure an appropriate response to consultant pharmacist recommendations for three of five residents reviewed for potentially unnecessary medications (Residents 37, 75, and 79).

Findings include:

Clinical record review for Resident 37 revealed a consultant pharmacist report dated June 26, 2023, requesting the facility monitor the effectiveness and potential adverse effects of Resident 37's Cymbalta (antidepressant medication) and ensure it was documented in the clinical record regularly.

Further review of Resident 37's clinical record revealed no evidence that the facility addressed the June 2023 consultant pharmacist recommendation.

Clinical record review for Resident 75 revealed a consultant pharmacist report dated April 30, 2023, that requested a gradual dose reduction of Resident 75's Zoloft.

Further review of Resident 75's clinical record revealed Resident 75's physician did not address the April 2023 consultant pharmacist recommendation until July 11, 2023.

Clinical record review for Resident 79 revealed a consultant pharmacist report dated October 25, 2023, revealed Resident 79 was recently admitted to the facility with an order for an antipsychotic medication Olanzapine 2.5 milligrams at night for "depression," despite this medication not being classified as an antidepressant. The pharmacist noted this medication is more than likely being used for sleep. Antipsychotics have a boxed warning for increased risk of mortality in older adults with psychosis related to dementia. Additionally, they are associated with other potentially serious adverse effects including movement disorders, metabolic abnormalities, and orthostatic hypotension. The consultant pharmacist requested the facility attempt to discontinue the medication and if a medication is needed for sleep, to consider Trazodone (antidepressant medication).

A consultant pharmacist report dated November 30, 2023, revealed Resident 79's clinical record contained no evidence of a diagnosis and/or documentation in the clinical record that supported the continued use of Tolterodine (medication used to treat overactive bladder) requesting the facility reevaluate continued use of/provide documentation in the clinical record, which supports clinical rationale for routine use.

A consultant pharmacist report dated December 21, 2023, requested the facility reduce Resident 79's Tolterodine to 2 milligrams a day.

Further review of Resident 79's clinical record revealed no evidence that Resident 79's physician addressed the October, November, or December 2023, consultant pharmacist recommendations.

483.45(c)(1)(2)(4)(5) Drug Regimen Review
Previously cited deficiency 2/24/23

28 Pa. Code 211.2(d)(3)(8)(9) Medical director

28 Pa. Code 211.9(k) Pharmacy services

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


 Plan of Correction - To be completed: 03/25/2024

1. Physicians for residents 37, 75, and 79 will be given pharmacy recommendations again for review and address.

2. An audit will be conducted of the last full month of pharmacy recommendations. Any recommendations outstanding will be resubmitted. A tracker will be established to capture the pharmacy recommendations requiring signature. Any recommendations that are outstanding will be reviewed during monthly Quality Assurance.

3. Re-education by the NHA or designee will be provided to the DON and ADON regarding the requirement of addressing pharmacy recommendations.

4. An audit of pharmacy recommendations will be conducted monthly x 2 by DON or designee. Audit results will be reviewed by the Quality Assurance Performance Improvement Committee to determine resolution or need for continuation of audit process.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by four of four residents reviewed (Residents 26, 52, 75, and 79).

Findings include:

Clinical record review for Resident 26 revealed the facility admitted her on December 6, 2023, with diagnoses including severe dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) with agitation and dementia with behavioral disturbances. A review of Resident 26's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated December 12, 2023, indicated that the facility assessed Resident 26 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 26's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.

Clinical record review for Resident 52 revealed the facility admitted her on August 7, 2020, with diagnoses including dementia with behavioral disturbances. A review of Resident 52's most recent annual MDS dated May 30, 2023, indicated that the facility assessed Resident 52 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 52's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.

Clinical record review for Resident 75 revealed the facility admitted her on May 20, 2021, with diagnoses including dementia with behavioral disturbances. A review of Resident 75's most recent annual MDS dated May 29, 2023, indicated that the facility assessed Resident 75 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 75's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.

Clinical record review for Resident 79 revealed the facility admitted him on October 24, 2023, with diagnoses including dementia with behavioral disturbances. A review of Resident 79's admission MDS dated October 30, 2023, indicated that the facility assessed Resident 79 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 79's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.

The findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on January 31, 2024, at 2:25 PM. Further interview with the Director of Nursing and Employee 1 (assistant director of nursing) on February 2, 2024, at 8:21 AM confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Residents 26, 52, 75, and 79's dementia and cognitive loss.

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


 Plan of Correction - To be completed: 03/25/2024

1. The care plans for residents 26, 52, 75 and 79 will be updated to reflect individualized person-centered care plan interventions for dementia and cognitive loss.

2. An audit of the care plans for current residents with a diagnosis of dementia will be completed with care plans updated as needed to capture individualized person-centered interventions to address dementia.

3. Education will be conducted by ADON or designee to licensed nursing staff, Social Services and RNAC staff regarding the requirement to include individualized person-centered care plan interventions for dementia.

4. An audit of any new care plans will be conducted weekly x 3 and monthly x 2. Audit results will be reviewed by the Quality Assurance Performance Improvement Committee to determine resolution or need for continuation of audit process.

483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination: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.
§483.10(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

§483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

§483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

§483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

§483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:

Based on review of select facility policy and procedures, observations, and resident and staff interviews, it was determined that the facility failed to ensure that residents could make choices about aspects of their lives that were significant to them, such as smoking, for one of 32 residents reviewed (Resident 315).

Findings include:

The facility policy entitled, "Smoking Policy Skilled Nursing Facility," last reviewed without changes on January 25, 2024, revealed the facility is a smoke free building. The policy of the facility was to ensure that smoking was only permitted in a designated area and was done in a safe manner. New residents will be informed that the facility is smoke free; and they are welcome to reside here but may not smoke.

The procedure indicated that the skilled nursing center has a designated smoking area on the porch outside the main lobby for visitors to smoke. Staff are permitted to smoke during break times in areas indicated by signs as a "designated smoking area" to include the smoke shack off the skilled nursing facility and the designated smoking areas at the apartments, or in their vehicle.

Interview with Resident 315 on January 30, 2024, at 1:15 PM revealed that she does smoke but that the facility indicated they are a non-smoking facility, so she is not able to smoke here. She indicated that it was driving her nuts.

Further interview of Resident 315 on January 31, 2024, at 10:30 AM after she requested to see the surveyor, revealed that she wanted to know what the facility smoking policy was and what the "rules" were related to smoking because she was hearing two different stories. She indicated that she was told on admission that the facility was non-smoking but that a nurse last night told her that staff and visitors smoke at the facility. She also indicated that she is manic depressive (a mental health disorder that causes extreme mood swings from emotionally high to emotionally low) and with her pain slowly getting under control, and that fact that she is "not allowed to smoke she can feel herself slipping into a low spot."

The Nursing Home Administrator and Director of Nursing were made aware of Resident 315's concerns related to smoking during a meeting on January 31, 2024, at 2:15 PM. They confirmed that staff and visitors could smoke at the facility in designated areas but that residents are not allowed to smoke. They also confirmed that residents are made aware of this on admission.

The facility failed to ensure that a resident of the facility that desired to smoke, could smoke on premises in the facility designated smoking areas that are available to visitors and staff.

28 Pa. Code 201.29(j) Resident rights


 Plan of Correction - To be completed: 03/25/2024

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Williamsport Home agrees with the allegations and citations listed on the statement of deficiencies. The Williamsport Home maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Williamsport Home's written credible allegation of compliance. By submitting this plan of correction, The Williamsport Home does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Williamsport Home reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

1. A grievance form was completed with resident 315 on 2/1/2024. Nursing Home Administrator spoke with residents and again offered a nicotine patch. Upon her choice to not utilize a patch alternative placement in a facility permitting resident smoking was offered. The resident had a successfully planned discharge home on 2/12/24.

2. No other current residents in the facility have showed interest in smoking. The facility has reviewed the admission process and has reimplemented the resident handbook, which provides the residents with our smoking policy at the time of admission. Current residents in the facility will be provided the re-implemented resident handbook.

3. Education will be completed with Admissions Director and Admissions and Discharge Nurse by the Director of Nursing or designee regarding the requirement to provide and review the resident handbook at the time of admission. Staff will be educated upon hire on the smoking policy and annually. Re-education to all staff will be conducted to inform them of the employee policy for smoking.

4. The Nursing Home Administrator or designee will review for acknowledgement that the resident handbook was provided and reviewed at the time of admission x 3 and monthly x 2. Audit results will be reviewed by the Quality Assurance Performance Improvement Committee to determine resolution or need for continuation of audit process.



483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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.
§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on closed clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to ensure reconciliation of controlled medications upon discharge for one of three residents reviewed (Resident 111).

Findings include:

Review of Resident 111's closed clinical record revealed that she expired and was discharged from the facility on December 2, 2023. Resident 111 had current physician orders for Oxycodone (a narcotic used to treat pain) 5 mg (milligrams) every four hours as needed for pain and Ativan (medication used to treat anxiety) 0.5 mg two times a day as needed for anxiety.

There was no documented evidence in Resident 111's closed clinical record to indicate that the facility accounted for the disposition of her controlled medications upon her discharge. There was no documented evidence to indicate if the controlled medications were destroyed, returned to the pharmacy, or diverted.

Interview with the Director of Nursing on February 2, 2024, at 8:13 AM confirmed the above findings for Resident 111.

28 Pa. Code 211.9 (j.1)(4)(5) Pharmacy services

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


 Plan of Correction - To be completed: 03/25/2024

1. The disposition of controlled medication cannot be changed. The facility located narcotic sheets with disposition noted post survey exit.

2. The facility will audit the last month of discharges to ensure narcotic sheet was completed and signed off on for destruction/disposition of the medication. Moving forward, the ADON or designee will review discharged resident narcotic sheets to ensure completion.

3. Re-education will be provided to the licensed nursing staff by ADON or designee of proper documentation of narcotic destruction.

4. An audit of discharges and their narcotic sheets will be audited by ADON or designee weekly x 3 and monthly x 2. Audit results will be reviewed by the Quality Assurance Performance Improvement Committee to determine resolution or need for continuation of audit process.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan: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.
§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement a baseline care plan that included instructions needed to provide effective care for one of four residents reviewed (Resident 314).

Findings include:

Clinical record review for Resident 314 revealed that the facility admitted her on January 25, 2024, with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), mood disturbance (feelings of distress or sadness), psychotic disturbance (a mental disorder characterized by a disconnection from reality), and anxiety (intense, excessive, and persistent worry and fear about everyday situations).

Further clinical record review for Resident 314 revealed a behavioral progress noted dated January 28, 2024, at 9:58 AM that indicated the resident was hitting the nurse and nurse aide multiple times during morning care. The note indicated she was very combative and unable to redirect.

A social service progress noted dated January 29, 2024, at 10:10 AM revealed that the social worker met with Resident 314 and her son. The note indicated that the resident likes arranging flowers, puzzles, spending time with her grandchildren, walking, and gardening. The note indicated that the son revealed that Resident 314 does become both physically and verbally aggressive due to her dementia diagnosis. He also indicated that her behaviors can be activated by loud/noisy environments. He stated that when she is agitated it is best to give her space, if safe to do so, reapproach by using a calm soft voice, and for staff to provide cueing prior to any care or she may become combative if staff try to provide care without telling her or try to rush her.

A behavioral progress note date January 29, 2024, at 2:07 PM revealed that Resident 314 continued with yelling and combativeness with staff. She was worse during morning care and when taking her to the bathroom.

A behavioral progress note dated January 31, 2024, at 7:38 AM revealed that Resident 314 did well, but became anxious at times. She became severely agitated when asked to remain seated or when staff tried to wash the urine off her. She hit the nurse in the face two times. She was redirected to focus on sitting down and to get cleaned up and redressed.

Review of Resident 314's baseline care plan revealed that the facility did not implement a person-centered behavioral care plan or interventions that were suggested by son when social services interviewed him.

Interview with the Nursing Home Administrator, Director of Nursing and Employee 1, Assistant Director of Nursing, on February 1, 2024, at 2:42 PM confirmed that a care plan related to Resident 314's behaviors to include preventative interventions was not implemented until after the surveyor brought this to their attention on January 31, 2024.

The facility failed to implement a person-centered baseline care plan to address Resident 314's behaviors.

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


 Plan of Correction - To be completed: 03/25/2024

1. The baseline care plan for resident 314 was updated to reflect specific person-centered behavioral interventions as identified by the resident representative.

2. An audit of current resident baseline care plans will be conducted to ensure behavioral interventions are listed if applicable. Care plans will be updated to reflect interventions as identified.

3. Education will be conducted by ADON or designee for RNAC staff and Social Workers regarding addition of person-centered behavioral interventions.

4. An audit of new baseline care plans will be audits weekly x 3 and monthly x 2 to ensure behavior care plans contain person-centered interventions for care. Audit results will be reviewed by the Quality Assurance Performance Improvement Committee to determine resolution or need for continuation of audit process.

483.20(g) REQUIREMENT Accuracy of Assessments:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one of 24 residents reviewed (Resident 78).

Findings include:

Review of Resident 78's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated January 8, 2024, that indicated nursing staff assessed Resident 78 as being administered insulin injections.

Review of Resident 78's physician orders did not include evidence of insulin medication.

Interview with the Nursing Home Administrator, Director of Nursing, and Employee 1 (assistant director of nursing) on February 1, 2024, at 2:38 PM confirmed the MDS was incorrect and Resident 78 did not receive insulin during the lookback period.


28 Pa. Code 211.5(f) Clinical records

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


 Plan of Correction - To be completed: 03/25/2024

1. The MDS for resident 78 was modified to remove the insulin injection at MDS item N0350A.

2. The most recent MDS for residents currently ordered Ozempic will be audited with modifications completed as necessary.

3. Education will be conducted with RNAC staff by NHA or designee regarding correct coding of insulin injections on the MDS.

4. An audit of residents receiving Ozempic will be conducted Weekly x 3 and monthly x 2. Audit results will be reviewed by the Quality Assurance Performance Improvement Committee to determine resolution or need for continuation of audit process.

§ 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 Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on staff interview and documentation review, it was determined that the facility did not comply with the requirements of the Act 52 Infection Control Plan.

Findings include:

The 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 improving the health and safety of residents and health care workers and should include a multidisciplinary committee including a representative from each of the following, if applicable, to the specific health care facility:

(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 patient safety officer
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee, or contractor of the health care facility.

Interview with Employee 3, Infection Control Preventionist on February 2, at 9:35 AM revealed that the facility had no evidence of attendance of all required committee members at the infection control meetings. Review of attendees' signatures revealed that the facility had no evidence that laboratory personnel or a community member attended the meetings.


 Plan of Correction - To be completed: 03/25/2024

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Williamsport Home agrees with the allegations and citations listed on the statement of deficiencies. The Williamsport Home maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Williamsport Home's written credible allegation of compliance. By submitting this plan of correction, The Williamsport Home does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Williamsport Home reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

1. The facility is not able to go back and update the past infection control meeting attendance.

2. The facility will re-educate required committee members on the requirement for attendance at scheduled meetings.

3. Re-education will be conducted by ADON or designee to the Infection Preventionist on the committee member requirements.

4. An audit of the next three infection control meetings will be audited by DON or designee to ensure compliance. Audit results will be reviewed by the Quality Assurance Performance Improvement Committee to determine resolution or need for continuation of audit process.

§ 211.9(j.1) (1) - (5) LICENSURE Pharmacy services.:State only Deficiency.
(j.1) The facility shall have written policies and procedures for the disposition of medications that address all of the following:
(1) Timely and safe identification and removal of medications for disposition.
(2) Identification of storage methods for medications awaiting final disposition.
(3) Control and accountability of medications awaiting final disposition consistent with standards of practice.
(4) Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.
(5) A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

Observations:

Based on closed clinical record review and staff interview, it was determined that the facility failed to document the accounting and disposition of medications in the clinical record upon discharge for one of three residents reviewed (Resident 111).

Findings include:

Clinical record review for Resident 111 revealed that she expired, and the facility discharged her on December 2, 2023.

There was no documented evidence in Resident 111's closed clinical record of the disposition of the following medications: Eliquis (a blood thinner) 2.5 mg (milligrams), Mirtazapine (treats major depression) 30 mg, Mirabegron (treats increased urinary frequency) 50 mg, and Lisinopril (treats high blood pressure) 10 mg. There was no documented evidence to determine if the medications were destroyed or returned to the pharmacy.

Interview with the Director of Nursing on February 2, 2024, at 8:13 AM confirmed that the facility was unable to provide documented evidence of appropriate disposition of Resident 111's medications upon her discharge.


 Plan of Correction - To be completed: 03/25/2024

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Williamsport Home agrees with the allegations and citations listed on the statement of deficiencies. The Williamsport Home maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Williamsport Home's written credible allegation of compliance. By submitting this plan of correction, The Williamsport Home does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Williamsport Home reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

1. The facility is not able to change the missing disposition of medications for resident 111.

2. An audit of medication dispositions will be completed on residents discharged in the last two months.

3. Education will be conducted by ADON or designee to licensed staff on the requirements of completion of a medication disposition sheet upon discharge.

4. An audit of medication dispositions of discharged residents will be completed by DON or designee weekly x 3 and then monthly x 2. Audit results will be reviewed by the Quality Assurance Performance Improvement Committee to determine resolution or need for continuation of audit process.


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