Pennsylvania Department of Health
BETHEL PARK SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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BETHEL PARK SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  122 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.
BETHEL PARK SKILLED NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to two complaints completed on February 6, 2024, it was determined that Bethel Park Skilled Nursing and Rehabilitation Center was not in compliance with the following 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 related to the health portion of the survey process.


 Plan of Correction:


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:
Based on a review of facility policy, facility provided documents and staff interview, it was determined the facility failed to follow infection control practices related to COVID 19, and risked the potential for the spread of the virus, in four of four resident rooms ( Rooms 109, 114, 225 and 242).

Findings include:

Review of facility policy titled "COVID-19 Testing and Management of: Symptomatic Person, Close Contacts and Outbreaks" last reviewed 1/18/24, informed once the patient has been discharged, transferred, or transmission based precautions have been discontinued, the room should undergo appropriate cleaning and surface disinfection before it is returned to routine use. EVS (Environmental Services) Director should complete the Discharge/Turnover Checklist when a patient is taken off precautions, transferred or discharged.

Review of facility policy titled "Discharge/Turnover Room Cleaning," last reviewed 1/18/24, informed resident/patient rooms are cleaned and disinfected after discharge/turnover. Turnover is defined as discontinuation of Transmission Based Precautions. The purpose is to ensure rooms are cleaned, disinfected, and prepared for admission. The information is recorded on the Discharge/Turnover Room Checklist.

Review of facility provided document titled "Resident Outbreak Line List for COVID-19" revealed the facility had five residents that tested positive for COVID-19 in January, 2024. Two of those residents shared a room. Room numbers associated with the resident discontinuation of transmission based precautions are as follows:
Room 109 - 1/20/24
Room 114 - 1/14/24
Room 225 - 2/6/24
Room 242 - 1/18/24

During an interview on 2/5/24, at 3:00 p.m. the Accounts Manager - Environmental Services Employee E2 reported when a resident comes off of transmission based precautions the room is cleaned and disinfected. The cleaning and disinfecting information is recorded on the facility form titled "Discharge/Turnover Room Checklist." The Accounts Manager - Environmental Services Employee E2 could not provide documentation of the cleaning and disinfection of Rooms 109, 114, 225, and 242 after the residents were discontinued from transmission based precautions.

During an interview on 2/5/24, at 3:15 p.m. the Account Manager - Environmental Service Employee E2 confirmed the facility failed to follow infection control practices related to COVID 19, and risked the potential for the spread of the virus.

28 Pa. Code: 201.14(a) Responsibility of licensee.

28 Pa. Code: 201.18(b)(1)(e)(1) Management.

28 Pa. Code: 211.10(d) Resident care policies.

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 03/01/2024

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Patients who resided in Room 109, Room 114, Room 225, Room 242 are no longer at the facility.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Daily Communication to Environmental Services regarding discontinued residents from transmission based precautions to occur and the Discharge/Turnover Room and/or Deep Cleaning Checklist will be completed to ensure proper cleaning techniques.


What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
Education provided to environmental services managers and staff to ensure understanding of transmission based precautions and process when Discharge/Turnover Room and/or Deep Cleaning Checklist.


How the corrective action will be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established?
The Accounts Manager - Environmental Services and/or designee will complete a weekly audit 5 times a week for 4 weeks for 2 months to ensure all the cleaning and disinfecting information is recorded on the facility form titled "Discharge/Turnover Room Checklist and/or deep cleaning checklist after the residents were discontinued from transmission based precautions. Results of audits will be reviewed monthly x2 at Quality Assurance Performance Improvement to determine if further audits will be needed.


Dates of when the corrective action will be completed. Mar 1, 2024


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