Pennsylvania Department of Health
HANOVER HALL FOR NURSING AND REHABILITATION
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HANOVER HALL FOR NURSING AND REHABILITATION
Inspection Results For:

There are  110 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.
HANOVER HALL FOR NURSING AND REHABILITATION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Revisit Survey completed on October 16, 2024, it was determined that Hanover Hall for Nursing and Rehabilitation did not correct all of the deficiencies cited during the survey of September 16, 2024, under the requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on staffing document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Nurse Aide (NA) per 10 residents on day shift for five of 7 days reviewed (October 9, 10, 11, 14, and 15, 2024), one NA per 11 residents on evening shift for five of 7 days reviewed (October 9, 10, 11, 12, and 13, 2024), and one NA per 15 residents on night shift for three of 7 days reviewed (October 12, 13, and 15, 2024) as calculated by full time equivalent (FTE - Number of staff required calculated by determining the required number of hours of full time shifts worked to meet the minimum staff to resident ratio).

Findings include:

Review of staffing information for the day shift of October 9, 2024, revealed a resident census of 116, which resulted in a minimum NA FTE of 11.60; submitted information revealed the facility provided 10.97.

Review of staffing information for the evening shift of October 9, 2024, revealed a resident census of 117, which resulted in a minimum NA FTE of 10.64; submitted information revealed the facility provided 10.10.

Review of staffing information for the day shift of October 10, 2024, revealed a resident census of 119, which resulted in a minimum NA FTE of 11.90; submitted information revealed the facility provided 11.23.

Review of staffing information for the evening shift of October 10, 2024, revealed a resident census of 119, which resulted in a minimum NA FTE of 10.82; submitted information revealed the facility provided 8.07.

Review of staffing information for the day shift of October 11, 2024, revealed a resident census of 119, which resulted in a minimum NA FTE of 11.90; submitted information revealed the facility provided 11.53.

Review of staffing information for the evening shift of October 11, 2024, revealed a resident census of 119, which resulted in a minimum NA FTE of 10.82; submitted information revealed the facility provided 8.57.

Review of staffing information for the evening shift of October 12, 2024, revealed a resident census of 119, which resulted in a minimum NA FTE of 10.82; submitted information revealed the facility provided 9.80.

Review of staffing information for the night shift of October 12, 2024, revealed a resident census of 119, which resulted in a minimum NA FTE of 7.93; submitted information revealed the facility provided 7.50.

Review of staffing information for the evening shift of October 13, 2024, revealed a resident census of 118, which resulted in a minimum NA FTE of 10.73; submitted information revealed the facility provided 9.27.

Review of staffing information for the night shift of October 13, 2024, revealed a resident census of 118, which resulted in a minimum NA FTE of 7.87; submitted information revealed the facility provided 6.97.

Review of staffing information for the day shift of October 14, 2024, revealed a resident census of 118, which resulted in a minimum NA FTE of 11.80; submitted information revealed the facility provided 9.37.

Review of staffing information for the day shift of October 15, 2024, revealed a resident census of 119, which resulted in a minimum NA FTE of 11.90; submitted information revealed the facility provided 11.33.

Review of staffing information for the night shift of October 15, 2024, revealed a resident census of 120, which resulted in a minimum NA FTE of 8.00; submitted information revealed the facility provided 7.47.

An email communication received from the Nursing Home Administrator on October 16, 2024, at 9:51 AM, indicated that she was aware the facility was still not meeting state mandated nurse aide ratios.

An email communication received from the Director of Nursing on October 16, 2024, at 4:19 PM, indicated that the expectation is for the facility to be staffed at state mandated ratios of nurse aides.






 Plan of Correction - To be completed: 11/07/2024

1. Facility cannot retroactively correct this concern
2. All residents are at risk of being affected by staffing levels. An audit of the grievance log on the days cited below staffing ratios will be audited for any grievances related to staffing.
3. Re-education was previously completed with nursing staff on staffing and minimum requirements. Facility continues to partner with company in recruiting for the CNA classes. Will continue to offer bonuses when ratios are below minimum, and mandate as needed when call outs and absences occur. Facility will re-evaluate agency rates to increase CNA staffing
4. NHA/designee will monitor staffing ratios and PPD daily to ensure appropriate levels are being met. Audits will be reviewed at QAPI to ensure compliance and quality care.


§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on facility staffing documentation review and staff interview, it was determined that the facility failed to meet the minimum of 3.20 hours of direct resident care for each resident for four of seven days reviewed (October 10, 11, 13, and 14, 2024).

Findings include:

Review of facility submitted staffing information revealed the following dates had not met the minimum of 3.20 hours of direct resident care for each resident:
October 10, 2024, the facility provided 2.95.
October 11, 2024, the facility provided 3.12.
October 13, 2024, the facility provided 3.17.
October 14, 2024, the facility provided 3.12.

An email communication received from the Nursing Home Administrator on October 16, 2024, at 9:51 AM, indicated that she was aware the facility was still not meeting state mandated direct care staffing hours.

An email communication received from the Director of Nursing on October 16, 2024, at 4:19 PM, indicated that the expectation is for the facility to be staffed at state mandated direct care hours.








 Plan of Correction - To be completed: 11/07/2024

1. Facility cannot retroactively correct this concern
2. All residents are at risk of being affected by staffing levels. An audit of the grievance log on the days cited below staffing PPD will be audited for any grievances related to staffing.
3. Re-education was previously completed with nursing staff on staffing and minimum requirements. Facility continues to partner with company in recruiting for the CNA classes. Will continue to offer bonuses when PPD is below minimum, and mandate staff as needed when call outs and absences occur. Facility will re-evaluate agency rates to increase CNA staffing.
4. NHA/designee will monitor staffing ratios and PPD daily to ensure appropriate levels are being met. Audits will be reviewed at QAPI to ensure compliance and quality care.



Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port