Pennsylvania Department of Health
MEADVILLE MEDICAL CENTER, TRANSITIONAL CARE UNIT
Patient Care Inspection Results

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MEADVILLE MEDICAL CENTER, TRANSITIONAL CARE UNIT
Inspection Results For:

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MEADVILLE MEDICAL CENTER, TRANSITIONAL CARE UNIT - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare Recertification, State Licensure, and Civil Rights Compliance Survey completed on December 14, 2023, it was determined that Meadville Medical Center TCU 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.




 Plan of Correction:


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 review of manufacturer's guidelines, facility records, observations, and staff interviews, it was determined the facility failed to maintain safe storage of ice for residents for one of one ice machines located in the kitchen.

Findings include:

Review of the manufacturer's guidelines for the "Kold-Draft GT & GB Models" (ice machine) revealed that "Individual drains must never be directly connected to a common manifold, drain, or standpipe. If individual drains are to be discharged into a common manifold, drain, or standpipe, a minimum one and half-inch air gap must be provided at each connection. This is to prevent any backflow or back-siphoning of drain water into the ice maker or ice bin."

Review of ice machine maintenance records provided by the facility on 12/12/23, indicated that the ice machine was last serviced and cleaned on 9/25/23.

Observation on 12/11/23, at 11:14 a.m. revealed a black, slimy substance on the outside of the white plastic drainpipe from the bottom of the ice bin. The bottom edge of the pipe was resting against the top edge of the drainpipe to the floor, and there was black, slimy substance on the inside edge of the drainpipe to the floor, and there was no one and half-inch air gap.

During an interview on 12/11/23, at 11:14 a.m. the Dietary Manager confirmed the presence of the black, slimy substance on both pipes and that the pipes were resting together.

During an interview on 12/12/23, at 1:30 p.m. the Nursing Home Administrator confirmed the presence of the black, slimy substance; the edges of the pipes were touching; the ice machine was last cleaned on 9/25/23; and that the ice machine piping was dirty and should have been cleaned and measures taken to prevent the development of the black, slimy substance.

28 Pa. Code 201.14(a) Responsibility of licensee









 Plan of Correction - To be completed: 01/15/2024

The ice machine discharge hose will be cut to achieve the 1.5" air gap required. The open air drain cup itself is sanitized as part of the ice machine preventive maintenance process but in order to improve the appearance of the inside and outside of the drain cup the drain cup will be cleaned and sanitized with an appropriate cleaning solution.

The existing preventive maintenance process form will be modified to insure that the 1.5"air gap is part of the preventive maintenance inspection procedure and is maintained at 1.5". The cleaning of the open air drain cup will part of the ice machine review process and cleaned as needed.

The director of facilities engineering or VP ancillary services will conduct facility inspections looking for Safety, Life Safety, Infection Control and aesthetic issues that need to be addressed and resolved. Ice machine open air gaps and drain cup appearance will be part of their inspection process. Additionally our Infection Prevention Team and the NHA have included the drain inspection as part of their monthly kitchen inspections beginning 12/19/2023. The inspection will be included on the inspection documentation that is reviewed at quartlerly Infection Prevention Committee meetings and quarterly QAPI meetings through 2024.
483.35(b)(1)-(3) REQUIREMENT RN 8 Hrs/7 days/Wk, Full Time DON: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.
§483.35(b) Registered nurse
§483.35(b)(1) Except when waived under paragraph (e) or (f) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

§483.35(b)(2) Except when waived under paragraph (e) or (f) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis.

§483.35(b)(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.
Observations:


Based on review of position description and job duties and facility documentation, and staff interviews, it was determined that the facility failed to ensure that a registered nurse was employed as the Director of Nursing on a full-time basis since October 26, 2023.

Findings include:

Review of the position description section for the Director of Nursing - (DON) revealed that the role of the DON includes to coordinate total nursing care for residents using nursing standards and the nursing process in accordance with current Federal, State, and Local standards, guidelines, and regulations that govern the Long Tern Care Facility to assure that the highest degree of quality care can be provided to our residents at all times.

The "Job Duties" for the DON included to promote an environment in which the resident care team can work cooperatively toward objectives, directs, supervises, delegates and evaluates all nursing care provided to the residents by using professional skills and judgements. Functions as clinical and managerial resource to guide and validate the independent decision making of staff.

Review of information submitted by the facility regarding a change in the DON position revealed that Employee EI began as the DON on November 6, 2023.

During an interview on December 13, 2023, at 10:30 a.m. DON Employee E1 reported he/she was serving as the temporary DON while they work to fulfill the job with a permanent employee. Employee E1 reported that they also work as the Nursing Supervisor in the acute care hospital two to three days a week.

During an interview on December 13, 2023, at 10:30 a.m. the Nursing Home Administrator confirmed that Employee E1 assumed the DON role on November 6, 2023, and the former DON's last day worked was on October 26, 2023. The NHA also confirmed that the current DON does not work on a full-time basis as they also work as the Nursing Supervisor in the acute care hospital two to three days a week.

28 Pa Code 201.14 (a) Responsibility of license

28 Pa Code 211.12 (b) Nursing Services






 Plan of Correction - To be completed: 01/31/2024

As of 12/24/2023, TCU has appointed a full-time interim DON. Her first day in this capacity was 12/26/2023. The DON schedule will be posted with RN schedules on posted staff scheduling log. The permanent DON position has been posted on our internal job board as well as outside employment sites. Interviews are ongoing.

NHA will confirm that the DON is scheduled full time by monitoring weekly through 01/20/2024, twice a month through 3/31/2024 and monthly after that date.
Compliance will be reported and documented at quarterly QAPI meetings in 2024.
§ 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 review of facility infection control records and staff interviews, it was determined that the facility failed to comply with the following requirements of MCARE Act 403(a)(1).

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.

1303.405(a)- Patient Safety Authority Jurisdiction states:

(a)The occurrence of a healthcare-associated infection is deemed a serious event. Written notification to the resident of the serious event should be documented.

A review of the facility Infection Control Program revealed that the facility failed to provide evidence of Pharmacy representation at the second quarter committee meeting held on 5/19/23, and Physical Plant representation at the first quarter meetings held 1/20/23, and 3/17/23, and third quarter meeting held 9/25/23.

During an interview on 12/14/23, at 10:30 a.m. the Nursing Home Administrator confirmed that the facility was not able to provide evidence of Pharmacy representation at the second quarter committee meeting held on 5/19/23, and Physical Plant representation at the first quarter meetings held 1/20/23, and 3/17/23, and third quarter meeting held 9/25/23.




 Plan of Correction - To be completed: 01/18/2024

Prior to the next Infection Prevention meeting, the NHA will send an email reviewing attendance requirements to all committee members to ensure a representative from each required discipline attends the quarterly meeting. At the next Infection Prevention meeting, Infection Prevention team will review with membership the requirements for attendance that if the committee member is unable to attend the IP meeting, they will send a designee in the place.

Infection Prevention team will review attendance after each meeting. If a representative from a required discipline is not in attendance, a nurse from Infection Prevention will review all of the meeting reports and discussion with a representative from that discipline prior to the next meeting. The review of the meeting will be noted in the minutes of the subsequent meeting.

The deficiency and correction plan will be reviewed at quarterly QAPI meetings through 2024.

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