Pennsylvania Department of Health
Nursing Homes Survey
Definitions

Plan of Correction

For each deficiency observed, the nursing home is required to submit a plan of correction unless the deficiency is considered both isolated and having the potential for causing no more than a minor impact on the residents (Rating A in the scope and severity descriptions).  The plan must include how the nursing home will correct the identified deficiencies and what system will be implemented to prevent reoccurrence. The nursing home must also indicate a target date for the correction of each deficiency.  The nursing home may also submit facts, with the Plan of Correction, to rebut or refute the Department's findings if they disagree with the Department's factual findings.

 

The Department will conduct a revisit to determine if the nursing home was successful in implementing the plan of correction.

 

Scope of deficiency: (isolated)

Scope of a deficiency is isolated when one or a very limited number of residents are affected and/or one or a very limited number of staff are involved, and/or the situation has occurred only occasionally or in a very limited number of locations.

 

Scope of deficiency: (pattern)

Scope of a deficiency is a pattern when more than a very limited number of residents are affected, and/or more than a very limited number of staff are involved, and/or the situation has occurred in several locations, and/or the same resident(s) have been affected by repeated occurrences of the same deficient practice, but the deficient practice is not pervasive throughout the nursing home.

 

Scope of deficiency: (widespread)

Scope of a deficiency is widespread when the problems causing the deficiency are pervasive in the nursing home and/or represents a systemic failure that has affected or has the potential to affect a large portion or all of the nursing home's residents.

 

Severity of deficiency: (potential for minimal harm)

The severity of a deficiency is defined as potential for minimal harm when the deficiency has the potential for causing no more than a minor negative impact on the resident[s].

 

Severity of deficiency: (minimal harm)

A deficiency is determined to have a severity level of minimal harm when it 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 as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services.

 

Severity of deficiency: (actual harm)

The actual harm level indicates that the deficiency has resulted in a negative outcome that has compromised the resident's ability to maintain and/or reach his/her highest practicable physical, mental and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services.

 

Severity of deficiency: (immediate jeopardy)

This level of severity indicates that the resident is in immediate jeopardy of a situation which has caused, or is likely to cause, serious injury, harm, impairment, or death as a result of the nursing home's noncompliance with one or more regulations.

 

Substandard Quality of Care

This item displays dates of surveys on which the Department made a finding that a nursing home had provided substandard quality of care. This is a technical regulatory term which means that one or more requirements under three specific federal regulations (42 CFR § 483.13- resident behavior and facility practices; 42 CFR § 483.15- quality of life; or 42 CFR § 483.25- quality of care) have not been met at a severity level which constitutes either immediate jeopardy to resident health or safety; a pattern or widespread actual harm that is not immediate jeopardy; or a widespread potential for more than minimal harm, but less than immediate jeopardy, with no actual harm. A finding of substandard quality of care indicates that the nursing home was found to have had a significant deficiency (or deficiencies) which the home must address and correct quickly to protect the health and safety of residents.