Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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

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Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, Civil Rights Compliance, and State Licensure Survey completed on February, 13, 2020, it was determined that Clarion Healthcare and Rehabilitation Center, 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:

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 State and local agencies responsible for the health and welfare of residents.

Based on review of facility infection control committee records and staff interviews, it was determined that the facility failed to comply with the following requirements of MCARE Act 403(a)(1) for four of four 2019 quarterly meetings (3/20/19, 6/18/19, 9/10/19, and 12/19/19).

Findings include:

MCARE Act, Section 403(a)(1), 40 P.S. 1303.403(a)(1) - Infection Control Plan, states:

(a) Development and compliance - Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include:
(1) A multidisciplinary committee including representatives 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 or ambulatory surgical facility.

A review of the facility Infection Control Program on 2/13/20, 9:43 a.m., revealed that the facility's infection control committee lacked community representation at the quarterly committee meetings held during the year 2019 on 3/20/19, 6/18/19, 9/10/19, and 12/19/19.

During an interview on 2/13/20, 9:43 a.m. the Director of Nursing confirmed the infection control meetings held in 2019, lacked community representation at the quarterly committee meetings.

 Plan of Correction - To be completed: 03/31/2020

Infection Control Committee records determined that the facility was lacking of having a representation from the community attending the infection control meeting quarterly. Per Act 52 the infection control meeting requires attendance from a community member. NHA/DON or designee will ensure that all future meeting for infection control will have representation by a community member. The facility has reached out to a community member that agrees to the community representation. NHA or DON will invite community member and a reminder notification will be provided prior to the meeting date. The IDT team will be educated on the ACT 52 requirement for community representation at quarterly meetings. This will be review at next QIPPA meeting. DON/HNA will monitor attendance records from Infection Control Meetings quarterly and ensure that a community member attended. If the invited community attendee is unable to attend the DON or designee will contact invited member and review meeting minutes. Signature will be obtained once reviewed by the community member.
211.9(g) LICENSURE Pharmacy services.:State only Deficiency.
(g) If over-the-counter drugs are maintained in the facility, they shall bear the original label and shall have the name of the resident on the label of the container. The charge nurse may record a resident's name on the nonprescription label. The use of nonprescription drugs shall be limited by quantity and category according to the needs of the resident. Facility policies shall indicate the procedure for handling and billing of nonprescription drugs.

Based on observations and staff interviews, it was determined that the facility failed to ensure that over-the-counter stock medications were labeled with the names of the residents who received those medications for two of two medication carts.

Findings include:

A review of medication storage, conducted on 2/10/20, from 11:40 a.m. through 12:31 p.m. revealed that the containers for 55 over-the-counter stock medications housed in both facility medication carts, did not bear a label containing the names of residents who were to receive the medications.

During an interview on 2/10/20, at 4:25 p.m. the Assistant Director of Nursing and Licensed Practical Nurse Employee E1 confirmed that the resident names of those who received the over-the-counter stock medications were not listed/identified on the containers' labels.

 Plan of Correction - To be completed: 03/31/2020

All Over the counter drugs will bear the original label and shall have the names for the residents taking the OTC displayed on the bottle. Facility failed to ensure that the OTC stock meds were labeled with the names of residents receiving the OTC. 2/10/20 Once identified as deficient practice all of the OTC's were immediately label with the resident names of who received the OTC's house wide. Then with every admission or new orders for the OTC's the RN supervisor will write on or remove the residents names to the OTC bottles. During red lining at night the RN supervisor will ensure that any orders for OTC will either be added or remove for the residents with new orders for OTC. The facility will conduct audits to ensure that new orders for OTC's are identified and that the residents name is either added or removed from the OTC bottle. All licensed staff will be educated on procedure of applying names of resident to OTC bottles. RN supervisor will add names or remove names per new orders and LPN will ensure that every resident's name appear on the bottle prior to administration of the OTC. DON/or assigned designee. Will monitor daily x 1wk then 3xwk x 1wks, then biweekly x1 and monthly x 1 or until 100 % compliant. All aduits will be review at monthly QIPPA.

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