Pennsylvania Department of Health
REHABILITATION CENTER AT JEFFERSON HILLS, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

REHABILITATION CENTER AT JEFFERSON HILLS, THE
Inspection Results For:

There are 128 surveys for this facility. Please select a date to view the survey results.

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REHABILITATION CENTER AT JEFFERSON HILLS, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance Survey completed on March 7, 2024, it was determined that The Rehabilitation Center at Jefferson Hills 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:

483.70(n)(2)(i)(ii)(3)-(5) REQUIREMENT Entering into Binding Arbitration Agreements:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

§483.70(n) Binding Arbitration Agreements
If a facility chooses to ask a resident or his or her representative to enter into an agreement for binding arbitration, the facility must comply with all of the requirements in this section.

§483.70(n)(1) The facility must not require any resident or his or her representative to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility and must explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility.

§483.70(n)(2) The facility must ensure that:
(i) The agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands;
(ii) The resident or his or her representative acknowledges that he or she understands the agreement;

§483.70(n)(3) The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it.

§483.70(n) (4) The agreement must explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility.

§483.70(n) (5) The agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman, in accordance with §483.10(k).

Observations:
Based on review of facility documents, resident and staff interviews it was determined that the facility failed to ensure the residents' right to not enter into a binding arbitration agreement as a condition of admission for 44 of 44 admitted residents.

Findings include:

Review of the "Admission Packet" list attachments as Attachment P "Voluntary Arbitration Agreement." Review of the Arbitration Agreement indicated that the agreement is voluntary. The agreement has been explained to the Resident and his or her Representative in a form and manner that he or she understands. The signature section at the end of the agreement stated "THE EXECUTION PAGE MUST BE SIGNED BY EITHER THE RESIDENT OR THE RESIDENT'S REPRESENTATIVE." This section did not include options to agree or disagree to enter into the binding arbitration agreement, or a refusal to sign.

Review of facility census information indicated 44 residents were admitted to the facility from 1/1/24, through 3/7/24.

During an interview on 3/7/24, at 11:00 a.m. Business Office Manager (BOM) Employee E2 confirmed that all residents sign the arbitration agreement. BOM Employee E2 stated that when she was trained on admissions procedures she was told that all residents needed to sign. BOM Employee E2 confirmed that the arbitration agreement forms did not provide the option of refusing to enter into the agreement, and that the signature of the resident or the resident's representative conveyed acceptance of the arbitration agreement.

During an interview on 3/7/24, at 11:14 a.m. the Nursing Home Administrator confirmed that the facility failed to ensure the residents' right to not enter into a binding arbitration agreement as a condition of admission.

28 Pa. Code 201.14(a)Responsibility of Licensee.

Plan of Correction - To be completed: 04/03/2024

1. Employee E2 has been educated on appropriate discussion about arbitration with Residents. Special emphasis will be on their right to refuse arbitration if so choosing to.
2. The Administrator or designee has instituted a new form where a clear designation of refusal can be opted for as well as freedom to choose any arbitration group.
3. The Business office manager will audit all new admissions for 2 weeks; then 3 x week for a period of a month to determine if appropriate arbitration agreement is being utilized.
4. The Activity Director will review the new arbitration agreement at the next resident council meeting to explain new process.
5. The Business office manager will complete a report for a period of one month to submit to QAPI on compliance with arbitration agreements.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§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 review of facility policy, water testing logs and staff interview, it was determined that the facility failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia) for eleven of eleven months (April 2023 through February 2024).

Findings include:

A review of the facility policy "Legionnaires' Disease Infection Control and Monitoring Policy" dated 2/12/24, did not include a water management program based on framework outlined in ASHRAE and CDC Standards identified as per the Maintenance Director Employee E1 and confirmed with the Nursing Home Administrator to minimize risk for Legionella associated with the building water systems at The Rehabilitation Center at Jefferson Hills.

During an interview on 3/7/24, at 1:00 p.m., Maintenance Director Employee E1 and the Nursing Home Administrator confirmed that the facility did not implement and effective water management program for the prevention and control of water-borne contaminants, such as Legionella since 2023.

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

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

28 Pa. Code: 201.20(c) Staff development.

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

Plan of Correction - To be completed: 04/03/2024

1. E1 Maintenance Director, along with DON, & ICP has been educated by the by the Administrator on effective water management program including appropriate time frames for Legionella and water testing
2. An effective water maintenance program has been implemented; no legionella detected.
3. The maintenance Director will test water sources monthly rotating sites each month and record. This will be done for a period of 6 months.
4. The maintenance Director will report compliance to QAPI monthly for a period of 6 months. The results of the legionella testing will be reported.

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime:

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(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.

Observations:
Based on a review of facility documentation and staff and resident interviews, it was determined the facility failed to ensure the provision of a substantial evening snack to the residents when up to 16 hours elapsed from the supper meal to breakfast the next day, and failed to garner resident group acceptance of a meal span of greater than 14 hours.

Findings include:

Review of facility's scheduled meal times revealed meal times revealed greater than 14 hours between dinner and breakfast.

Breakfast: North Unit 9:00 a.m.; South Unit 9:10 a.m.
Lunch: North Unit 1:00 p.m.; South Unit 1:10 p.m.; Dining Hall 1:15 p.m.
Dinner: North Unit 5:00 p.m.; South Unit 5:10 p.m.

During a resident group interview on 3/5/24, at 2:00 p.m. the residents stated that snacks at night are usually potato chips or snack puddings.

On 3/7/24, at approximately 10:30 a.m. documentation was requested from Activities Director Employee E3 that the resident group agreed to this meal span.

During an interview on 3/7/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to ensure the provision of a substantial evening snack to the residents when up to 16 hours elapsed from the supper meal to breakfast the next day, and failed to garner resident group acceptance of a meal span of greater than 14 hours.

28 Pa. Code 211.6(a)(b) Dietary services

Plan of Correction - To be completed: 04/03/2024

1. Meal times were modified to reflect less than 14 hours between any meal. Resident council has been appraised of this time change and have approved it.
2. The Dietary Manager of designee will monitor meal times for a period of one week to assure meals are delivered as scheduled.
3. The Dietary manager will complete an audit once a week for a period of a month to assure meals are being delivered as per schedule.
4. Administrator or designee will educate facility employees on new meal time policy.
5. The Dietary manager will report to QAPI for a period of one month on the compliance with meal times.

483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides:

§483.95(g) Required in-service training for nurse aides.
In-service training must-

§483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

§483.95(g)(2) Include dementia management training and resident abuse prevention training.

§483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.70(e) and may address the special needs of residents as determined by the facility staff.

§483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.

Observations:
Based on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for three of three nurse aides (Employees E4, E5, and E6).

Finding include:

Review of the policy "Staff Development" dated 12/11/23, previously reviewed 7/1/23, indicated "Nursing assistants shall receive at least 12 hours of in-service per year."

Review of Nurse Aide (NA) Employees E4, E5, and E6 education records revealed that each NA had documentation of eight hours of in-service training, and additional plan of correction training on abuse and neglect, visitation, and transfer status.

During an interview on 3/7/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide documentation of the required 12 hours annual in-service education within 12 months of their hire date anniversary for three of three nurse aides.

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

28 Pa. Code: 201.20(c) Staff development.

Plan of Correction - To be completed: 04/03/2024

1. The HR Director or Designee will conduct a facility wide assessment off all CAN's education to ensure they all received the required 12 hours. The HR Director or designee will train Employees E4, E5, E6. They will have been provided an additional 4 hours of certified nursing assistant education.
2. The HR Director will provide the Facility Certified Nursing assistants with an additional 4 hours of certified nursing assistant training.
3. The HR Director will audit 5 certified nursing assistants HR file weekly for a period of one month to assure all required training has been completed.
4. The HR director will submit to QAPI a report of compliance with Certified Nursing assistant training for a period of 2 months.

483.70(n)(2)(iii)(iv)(6) REQUIREMENT Binding Arbitration Agreements:

§483.70(n)(2) The facility must ensure that:
(iii) The agreement provides for the selection of a neutral arbitrator agreed upon by both parties; and
(iv) The agreement provides for the selection of a venue that is convenient to both parties.

§483.70(n)( (6) When the facility and a resident resolve a dispute through arbitration, a copy of the signed agreement for binding arbitration and the arbitrator's final decision must be retained by the facility for 5 years after the resolution of that dispute on and be available for inspection upon request by CMS or its designee.

Observations:
Based on review of the facility's admission agreement and staff interviews, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator for 44 of 44 residents admitted.

Findings include:

Review of facility's Admission Agreement packet, which contained the document "Voluntary Arbitration Agreement" indicated that "Accordingly, any dispute arising out of relating to the provision of services by the Facility to the Resident, Resident's admission to the Facility, Resident's contracts with the Facility or the subject matter thereof, any breach of contract, including any dispute regarding the execution, validity or scope of this Arbitration Agreement or any of its clauses, will be resolved through arbitration administered by [name of arbitrator services company which the facility utilized] and conducted pursuant to the [arbitrator] Rules of Procedure for Arbitration."

The facility's arbitration agreement failed to provide for the selection of a neutral arbitrator agreed upon by both parties as one is designated in the facility arbitration agreement, in accordance with (Regulatory guidance defined a neutral Arbitrator as an impartial, or unbiased third-party decision maker, contracted with, and agreed to by both parties to resolve their dispute. To ensure a neutral arbitrator is selected, the facility should avoid even the appearance of bias, partiality, or a conflict of interest, and should promptly disclose to the resident or his or her representative the extent of any relationship which exists with an arbitrator or arbitration services company, including how often the facility has contracted with the arbitrator or arbitration service, and when the arbitrator or arbitration service has ruled for or against the facility).

During an interview on 3/7/24, at 11:14 p.m. the Nursing Home Administrator confirmed the language of the arbitration agreement may appear not to afford the selection of a neutral arbitrator as it indicated that all arbitration are administered by the facility's contracted arbitration service.

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

28 Pa. Code 201.18(b)(2) Management.

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

Plan of Correction - To be completed: 04/03/2024

1. 1. Employee E2 has been educated on appropriate discussion about arbitration with Residents. Special emphasis will be on their right to select their own arbitration group and a neutral and fair arbitration process.
2. The Administrator or designee has instituted a new form where this a neutral and fair arbitration process.
3. The Business office manager will audit all new admission x2 weeks, then 3 per week for a period of a month to determine if appropriate arbitration agreement is being utilized.
4. The Activity Director will review the new arbitration agreement at the next resident council meeting to explain new process.
5. The Business office manager will complete a report for a period of one month to submit to QAPI on compliance with arbitration agreements for adhering to a neutral and fair arbitration process.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

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.

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to make certain that each resident's drug regimen was free from unnecessary drugs used without adequate indications and failed to provide medications in accordance with manufacturer's instructions for use for one of five residents (Resident R37).

Findings include:

Review of the U.S. Food and Drug Administration (FDA) prescribing information for Ziprasidone (anti-psychotic medication) revised 01/2020, indicated that Ziprasidone is used for the treatment of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior) and bipolar disease (a mental condition marked by alternating periods of elation and depression). Further review of this documented indicated this medication is to be given with food.

Review of the U.S. National Library of Medicine "The Impact of Calories and Fat Content of Meals on Oral Ziprasidone Absorption" dated 10/21/08, indicated that Ziprasidone should be taken with food and that a meal equal to or greater than 500 calories is required for optimal bioavailability of the administered dose.

During a resident group interview on 3/5/24, at 2:00 p.m. the residents stated that snacks at night are usually potato chips or snack puddings.

Review of the clinical record indicated Resident R37 was admitted to the facility on 7/12/23.

Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 12/3/23, included the diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and depressions. Further review of the MDS failed to include any diagnosis of a psychotic disorder, such as schizophrenia or bipolar disorder.

Review of the facility diagnosis list failed to include any diagnosis of a psychotic disorder.

Review of hospital discharge paperwork dated 7/11/23, included Ziprasidone 20 milligrams (mg), once daily.

Review of a physician's order dated 11/13/23, indicated for R37 to receive Ziprasidone HCL 20 mg, twice daily, as a mood stabilizer. Review of the order scheduling details indicated that this medication was ordered to be given at 9:00 a.m. and 9:00 p.m.

Review of a physician's order dated 10/26/23, indicated for Resident R37 to receive a psychology consult.

Review of Resident R37's clinical record failed to include a consultation completed with a psychological provider.

Review of Resident R37's plan of care for the use of psychotropic medications related to risk for negative mood/behavior related to a history of depression dated initiated 3/5/24, failed to include any goals or interventions related to behavior monitoring.

Review of behavior charting from October 2023, through February 2024, revealed the following:
October - Resident R37 documented as having no behaviors.
November - Behaviors not assessed.
December - Resident R37 documented as having no behaviors.
January - Resident R37 documented as having no behaviors.
February - Resident R37 documented as having no behaviors.

During an interview on 3/7/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that each resident's drug regimen was free from unnecessary drugs used without adequate indications and failed to provide medications in accordance with manufacturer's instructions for use for one of five residents.

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

Plan of Correction - To be completed: 04/03/2024

1. R 37 was seen by a psychologist from Valley Psychology Associates on 11/14/2023. An initial evaluation was completed. Subsequent follow up visits were completed on 1/25/24; 2/15/24 and 3/7/24. R 37 is stable and displaying no inappropriate behaviors. R 37's plan of care was updated to reflect goals and interventions related to behavior monitoring. The physician moved R 37's medication times to be coordinated with meal times as per manufacturers instruction. Valley Psych following the resident ongoing with treatment and plans of care.
2. The DON or designee will review all residents with antipsychotics medical records were reviewed to assure care plans, medication times and behavior monitoring is being completed. Reviewed all medical records to assure any resident with an order for psychological evaluation has been completed or scheduled.
3. The DON or designee will complete an audit once a week for a period of a month to review antipsychotics for appropriate care planning, medication administration and behavior monitoring, any discrepancies will be corrected.
4. The DON or designee will educate Licensed nursing staff on antipsychotic policies.
5. The DON or designee will submit a report to QAPI for one month to report on the compliance with antipsychotics.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:
Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for one of five residents (Resident R35).

Findings include:

Review of the facility policy "Pressure Ulcer Review" dated 12/11/23, previously reviewed 7/1/23, indicated that a resident with a pressure ulcer receives the necessary treatment and services to promote healing, prevent infections, and prevent new development.

Review of the clinical record indicated Resident R35 was admitted to the facility on 12/21/22.

Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 1/31/24, included the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and Down syndrome (a genetic disorder causing developmental and intellectual delays).

Review of a physician's order dated 1/3/24, to start on 1/4/24, indicated for staff to cleanse coccyx (area at the base of the spinal column) with normal saline, pat dry, apply collagen cover with calcium alginate (absorptive wound dressing ), cover with bordered gauze every day and as needed.

Review Resident R35's care plan dated for actual/potential for skin integrity impairment initiated 12/21/22, indicated for staff to administer treatments as ordered and monitor for effectiveness.

Review of Resident R35's Treatment Administration Record for January 2024 revealed that no documentation for completion of Resident R35's coccyx wound treatment completed from 1/4/24, through 1/15/24.

Review of a wound nurse nurse practitioner's progress note dated 1/17/24, at 6:51 p.m. indicated "Wound has deteriorated since last evaluation. Over the last few evaluations, the wound bed has been very clean with beefy red tissue. The wounds have converted to two separate areas; left and right buttock. They both have new foul drainage & slough (dead tissue that needs to be removed for wound to heal); as well as deeper depth. Concern for abscess pocket on the left buttock at the 5 o'clock location, when probed there is increased yellow drainage. Wound culture was sent due to abrupt change in wound appearance."

Review of a progress note dated 1/20/24, at 3:47 a.m. indicated "This nurse was called to residents room to look at wound on coccyx (right/left top buttock). Foul smell is present with gross amounts of foul smelling yellow/brown purulent (containing or producing pus) drainage. Left open area is 1 centimeter (cm) in diameter with tunneling (a wound that's progressed to form passageways underneath the surface of the skin) at 3 o'clock, 1cm tunneling six o'clock. Right open area slough is present with gross amounts or yellow foul smelling purulent drainage and tunnels at 3 o'clock of 1cm."

Review of a progress note dated 1/21/24, at 3:49 a.m. indicated "This nurse was called to room by staff due to dressing being saturated with foul copious amounts of purulent drainage. While performing wound care it was discovered that resident now has an open area in gluteal fold (horizontal crease of the buttock) midline to anus that tunnels to the original wound that measured 5 x 5 cm. As a nursing measure I cleaned entire area with normal saline and packed with 1/4 packing and Dakins (antiseptic solution) as calcium alginate and Santyl (ointment to remove dead skin) are futile at this time."

Review of a progress note dated 1/22/24, at 6:42 p.m. indicated "Wound Care Nurse was sent pictures of wound to coccyx and wanted the resident sent to the hospital for intravenous antibiotics. Resident was sent to [the hospital]."

Review of a progress note dated 1/26/24, at 1:26 p.m. indicated Resident R35 returned to the facility.

Review of a nurse practitioner follow-up dated 1/30/24, indicated that Resident R35 was hospitalized last week for a worsening wound.

During an interview on 3/7/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for one of five residents.

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

Plan of Correction - To be completed: 04/03/2024

1. R35 is stable and wounds are healing and free from infection. Treatment error was completed for all missing entries for R35 from 1/4/24 to 1/15/24.
2. The DON or designee will complete an audit of all Residents with current pressure areas to assure the treatments are being done timely and documented per physician's order
3. The DON or designee will complete a weekly observation audit on 5 Residents with pressure areas to assure TAR is complete and dressing are done in accordance with physician's orders
4. The DON or designee will educate licensed nurses on TAR completion and pressure ulcer policy.
5. The DON or designee will submit a report to QAPI for month to report on the compliance with pressure ulcer treatments.

483.95(a) REQUIREMENT Communication Training:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.95(a) Communication.
A facility must include effective communications as mandatory training for direct care staff.

Observations:
Based on review of facility policy and staff interviews, it was determined that the facility failed to provide training on effective communication to facility staff.

Findings include

Review of the policy "Staff Development" dated 12/11/23, previously reviewed 7/1/23, indicated the facility will provide all active employees with required training and education to include mandatory and corporately recommended staff training programs.

Review of faciltiy provided education documents failed to include that provision of training the facility staff on Effective Communication.

During an interview on 3/7/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide training on effective communication to facility staff.

28 Pa. Code 201.20(a)(b)(c)(d) Staff Development.

Plan of Correction - To be completed: 04/03/2024

1. The HR Director will educate all employees on facility Communication program.
2. The HR Director will add Communication education to the yearly/ and or hire in-services completed by employees.
3. The HR Director will audit new hire files a weekly for a period of one month to assure Communication education has been complete.
4. The HR Director will report to QAPI monthly on compliance with Communication education for a period of 2 months.

483.95(d) REQUIREMENT QAPI Training:

§483.95(d) Quality assurance and performance improvement.
A facility must include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program as set forth at § 483.75.

Observations:
Based on review of facility policy and staff interviews, it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program to facility staff.

Findings include

Review of the policy "Staff Development" dated 12/11/23, previously reviewed 7/1/23, indicated the facility will provide all active employees with required training and education to include mandatory and corporately recommended staff training programs.

Review of faciltiy provided education documents failed to include that provision of training the facility staff on the QAPI program.

During an interview on 3/7/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide training on the QAPI program to facility staff.

28 Pa. Code 201.20(a)(b)(c)(d) Staff Development.

Plan of Correction - To be completed: 04/03/2024

1. The HR Director will educate employees on facility QAPI program.
2. The HR Director will add QAPI education to the yearly/ and or hire in-services completed by employees.
3. The HR Director will audit 2 new employee files a week for a period of one month to assure QAPI education has been complete.
4. The HR Director will report to QAPI monthly on compliance with QAPI education for a period of 2 months.

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