Pennsylvania Department of Health
QUALITY LIFE SERVICES - GROVE CITY
Patient Care Inspection Results

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QUALITY LIFE SERVICES - GROVE CITY
Inspection Results For:

There are  114 surveys for this facility. Please select a date to view the survey results.

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QUALITY LIFE SERVICES - GROVE CITY - 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 January 25, 2024, it was determined that Quality Life Services-Grove City was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.












 Plan of Correction:


483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements: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.
§483.15(c) Transfer and discharge-
§483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i) Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.
Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to ensure the presence of necessary documentation to support the specific reasons for discharge versus returning to the facility after an emergency transfer to an acute care facility for one of three residents reviewed (Resident R1).

Findings include:

Review of Resident R1's clinical record revealed an initial admission date of 12/07/23, with diagnoses that included edema (swelling), dysphagia (difficulty swallowing) and short bowel syndrome (malabsorption disorder caused by lack of functional small intestine).

Review of a progress note, dated 12/09/23, and as a late entry, revealed that Resident R1 was displaying behaviors including verbal, throwing things, putting other residents at risk, interfering with resident care and participation in activities. Another nursing note at 1:00 p.m., revealed that Crisis was called and Resident R1 was transferred to an acute care facility on a 302 petition and evaluation.

Review of Resident R1's clinical record revealed that there was no physician documentation concerning the basis for the transfer/discharge; the specific resident's needs the facility could not meet; the facility efforts to meet the needs of the resident; and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility.

During an interview on 1/24/24, at 2:25 p.m. the Nursing Home Administrator confirmed the clinical record did not contain the required physician documentation as to the rationale that Resident R1's clinical symptoms could not be treated at the facility.

28 Pa. Code 201.29(a)(c) Resident rights








 Plan of Correction - To be completed: 03/08/2024

1. Cited resident is no longer in facility; placed elsewhere from hospital.
2. No other residents had a facility initiated discharge within last 3 months.
3. Medical Director and CRNP's will be educated by NHA on required criteria and documentation for facility initiated discharge.
4. Audits will be completed weekly x4 and monthly x3 by NHA or designee on all facility initiated discharges for compliance in meeting criteria with required documentation.
5. Results will be submitted to QAPI committee.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).
Observations:

Based on review of clinical records and facility policy and staff interview, it was determined that the facility failed to provide the resident and resident representative of a Notice before Transfer/Discharge in writing for one of three residents reviewed (Resident R1).

Findings include:

Review of the facility policy entitled "30 Day Discharge Notice AR-29" revealed "to ensure proper notice is given and to secure a safe discharge location per state regulations."

Review of Resident R1's clinical record revealed an initial admission date of 12/07/23, with diagnoses that included edema (swelling), dysphagia (difficulty swallowing) and short bowel syndrome (malabsorption disorder caused by lack of functional small intestine).

Review of Resident R1's clinical record revealed a progress note dated 12/09/23, at 1:00 p.m., which identified that Resident R1 was transferred to the hospital. The clinical record lacked documentation that Resident R1 and their representative was provided with a copy of a Notice of Transfer/Discharge as required.

During an interview on 1/24/24, at 2:25 p.m. the Nursing Home Administrator confirmed that there was no evidence that Resident R1 and his/her representative was provided with a copy of the Notice of Transfer/Discharge.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.29(a) Resident rights






 Plan of Correction - To be completed: 03/08/2024

1. Cited resident is no longer in the facility. Resident was placed elsewhere from the hospital.
2. Facility will review all discharges within last 30 days to ensure compliance with notifications.
3. All Licensed Nursing staff will be re-educated by DON/designee to review Transfer/Discharge Summary form and to ensure that it is completed correctly.
4. Social Service Director will be re-educated by NHA/Designee to review Transfer/Discharge Summary form and to ensure that it is completed correctly.
5. Audits will be completed weekly x 4 weeks and then monthly x 3 months by NHA/designee on all facility discharges to ensure that the Transfer/Discharge Summary has been completed and provided to the resident and/or resident's family member. Audits will also be completed to ensure that a discharge notice was issued and given to the resident and/or resident's family member for all facility initiated discharges if applicable.
6. Results of the audits will be submitted to QAPI committee.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon transfer to the hospital for one of three residents reviewed (Resident R1)


Findings include:

Review of the facility policy entitled "Bed Hold Policy" dated 2/23/23, indicated that during a temporary absence from the facility for a hospitalization or therapeutic leave, "during that absence, you will be offered the opportunity to reserve your residency."

Review of Resident R1's clinical record revealed an initial admission date of 12/0-7/23, with diagnoses that included edema (swelling), dysphagia (difficulty swallowing) and short bowel syndrome (malabsorption disorder caused by lack of functional small intestine).

Review of Resident R1's clinical record revealed a progress note dated 12/09/23 at 1:00 p.m., which identified Resident R1 was transferred to the hospital. The clinical record lacked documentation that Resident R1 and/or their representative was provided with a copy of the facility bed-hold policy.

During an interview on 1/24/24, at 2:25 p.m. the Nursing Home Administrator confirmed that there was no evidence that Resident R1 and/or his/her representative was provided with a copy of the facility bed-hold policy upon transfer or during absence from the facility.

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




 Plan of Correction - To be completed: 03/08/2024

I hereby acknowledge the CMS 2567-A, issued to QUALITY LIFE SERVICES - GROVE CITY for the survey ending 01/25/2024, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

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