Pennsylvania Department of Health
BUCKTAIL MEDICAL CENTER
Patient Care Inspection Results

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BUCKTAIL MEDICAL CENTER
Inspection Results For:

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BUCKTAIL MEDICAL CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a State Licensure Monitoring survey completed on December 13, 2023, it was determined that Bucktail Medical Center was not in compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


201.18(d.1)(1) LICENSURE Management.:State only Deficiency.
(d.1) The administrator appointed by the governing body under 42 CFR 483.70(d)(2) shall be currently licensed and registered in this Commonwealth and shall be employed full-time in facilities that have more than 25 beds. Facilities with 25 beds or less may share an administrator provided that all of the following apply:
(1) The Department is informed of this arrangement.

Observations:

Based on review of facility documents submitted to the State Field Office, it was determined that the governing body of the facility failed to ensure appointment of an administrator licensed by the State as of December 6, 2023.

Findings include:

Review of a letter submitted by the facility to the State Field Office dated December 6, 2023, indicated the previous Nursing Home Administrator, Employee 1, resigned from the facility effective immediately. The letter also indicated Employee 2, registered nurse and chief nursing officer had agreed to step in as the full-time administrator while the recruitment and hiring of a new Administrator was completed.

There was no evidence Employee 2 holds an administrator license by the State.

As of December 13, 2023, there was no evidence to indicate the facility hired a licensed administrator.

The facility's governing body failed to appoint an administrator licensed and registered in the Commonwealth.


 Plan of Correction - To be completed: 01/02/2024

On December 4, 2023 a Board member reached out to the State Board of Examiners of Nursing Home Administrators and left a message. On December 5, 2023 at 0955, the board member received a call back from State Board of Examiners of Nursing Home Administrators and were instructed to have Employee 2 complete the application for a temporary permit to act as a nursing home administrator.
The Board of Directors at their emergency meeting on December 6, 2023 appointed Employee 2, RN CNO to apply "temporary permit to act as a nursing home administrator" under 29 PA. B. 1949.

The Board of Directors also appointed 2 board members to appear before the State Board with Employee 2, if required.

Employee 2 submitted the temporary nursing home administrator application to the State Board of Examiners of Nursing Home Administrators on December 7, 2023 with required documentation, via certified mail. The appearance in person before the state board is pending and will be scheduled if required.

Employee 2 completed the Criminal Background Check, required for the above application on December 6, 2023.

December 18, 2023 the deficiency report was provided to the Board of Directors. Additional education will be provided to the Board regarding the process for obtaining a "temporary manager" in cases of unexpected administrator vacancies, at the next formal board meeting, which will be December 29.
The facility Board of Director Orientation was revised on December 18, 2023 to include regulatory requirements for LTC administrator certification requirements and the process for obtaining "temporary managers" for vacant administrator positions. This orientation and education will be provided to any newly appointed Board member.

Education will be reviewed with all board members and any new members. Members will attest that they have reviewed and understand the education.

No residents have been affected by this deficiency. There have been no interruptions in care or staffing.
Nursing staff oriented to changes in administration, and will report resident concerns to administration.

In the future, in the event of an unpredictable or sudden vacancy in administration, the board will first reach out to a Fully Licensed Nursing Home Administrator.

Employee #1 has applied for a temporary NHA license, this is pending at the State BPOA. Employee #1 will seek the formal education to become a LNHA at the direction of the Board of Directors.

Should the temporary permit be denied, the Board of Directors is prepared to reach out to Core Medical Group, and or Indeed to bring on a locum LNHA immediately.


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