Nursing Investigation Results -

Pennsylvania Department of Health
CORNER VIEW NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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CORNER VIEW NURSING AND REHABILITATION CENTER
Inspection Results For:

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CORNER VIEW NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey, completed on August 27, 2020, it was determined that Corner View Nursing and Rehabilitation Center, was not in compliance with the 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 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.
483.60(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 a review of facility policies, observations and staff interviews, it was determined that the facility failed to maintain proper sanitary conditions, air dry equipment and perform handwashing in the Main Kitchen (Main Kitchen).

Findings include:

A review of facility "HACCP (Hazard Analysis Critical Control Point) and Food Safety" policy dated 4/15/2020, indicated that facility is aware that sources for food - borne organisms are from contaminated equipment, improper sanitation and cross contamination.

A review of facility "Food Storage " policy date 4/15/2020, indicated that scoops are provided for bulk food such as sugar and flour. Scoops are not to be stored in the food.

A review of facility "General Sanitation of Kitchen" policy dated 4/15/2020, indicated that the staff shall maintain the sanitation of the kitchen by completing a cleaning schedule.

A review of facility "Dry Storage Areas" dated 4/15/2020, revealed that ceilings must protect food from leaking pipes or contamination.

A review of facility " Employee Sanitary Practices" policy dated 4/15/2020, indicated that guidelines for handling clean silverware include that staff is to pick up silverware by their handles.

A review of facility "Hand Washing" policy dated 4/15/2020, indicated that hand washing is performed after handling soiled equipment or utensils and after engaging ina activities that contaminate the hands.

During an observation of the Main Kitchen on 8/24/2020, at 8:45 am the following was revealed:
- the top of the convection oven contained a build up of dust and debris.
- a bulk container of sugar contained a scoop stored in the food product with the handle in direct contact of the food product.
- in the dry storeroom a ceiling tile was missing from the ceiling.
- in walk in refrigerator number two the shelving contained a build up a black substance.

During an interview on 8/24/2020, at 9:00 am the Food Service Supervisor Employee E12 confirmed that the facility failed to maintain the Main Kitchen in proper sanitary condition which created the potential for cross contamination.

During an observation on 8/25/2020, at 11:18 am Dietary Aide Employee E13 was observed with gloved hands used a terry cloth towel to dry meal service trays. He then placed the towel on the countertop, placed a napkin on the tray and then placed silverware on the napkin touching the eating portion of the utensil with the same gloved hands. He proceeded to pick up the towel from the countertop and repeat the procedure for the next tray.

During an interview on 8/25/2020, at 11:40 am. Food Service Supervisor Employee E12 confirmed that Dietary Aide Employee E13 improperly wiped meal service trays with a terry cloth failing to allow the equipment to air dry and to properly handle silverware by the handle which created the potential for cross contamination.

28 Pa Code: 211.6 (c)(f) Dietary services
Previously cited: 2/19/19, 5/16/18, and 3/30/18








 Plan of Correction - To be completed: 10/06/2020

The Food Service Director immediately cleaned the top of the oven, removed the scoop from the sugar, had the Maintenance Director replace the ceiling tile, and cleaned the shelving in the number 2 refrigerator.

The Food Service Director immediately corrected the process with the staff member that was drying the meal tray with a terry cloth towel.

A complete deep clean of the Kitchen will be completed. The staff will report Maintenance issues directly to the Maintenance Director or through our Maintenance electronic log system.

Additional meal trays will be purchased in order to have extra clean and dry trays in circulation. Drying racks will also be purchased in order to allow the meal trays to properly air dry.

The Administrator or designee will educate all kitchen staff on a clean and sanitary kitchen, use of scoops in bulk food, maintenance notification, proper hand washing, glove usage, and cross contamination of food.

Any new hires to the Dietary department will be educated by the Food Service Manager or designee prior to receiving an assignment

The Food Service Director or designee will complete an audit on a clean and sanitary kitchen and the cleaning schedule daily for 4 weeks then 3 times a week for 2 months.

The Food Service Director of designee will complete an audit on food storage and dry food storage daily for 4 weeks then 3 times a week for 2 months.

The Food Service Director of designee will complete an audit Employee sanitary practices and hand washing daily for 4 weeks then 3 times a week for 2 months.

The results of the audits will be reviewed by QAPI committee meeting for compliance for 3 months. The committee will determine compliance and the need for continued audits or any additional plan of action.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly: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)(4)- Dispose of garbage and refuse properly.
Observations:

Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to maintain the outdoor refuse area in a sanitary condition to prevent the potential for rodent and pest infestation. (Outdoor refuse area).

Findings include:

A review of facility " Food Safety - Food Service manager's Responsibility" dated 4/15/2020, indicated that the Food Service manager to to make certain that proper waste disposal methods are used.

During an observation of the outdoor refuse area on 8/24/2020, at 9:05 am revealed the following:
- the lids and one door were open on one dumpster that contained bags of garbage and broken medical equipment.
- doors on both side were open on a second dumpster that contained bags of garbage.
- there were spilled liquid and food debris on the asphalt located outside of both dumpster areas.
- at a separate area along the entrance to the refuse area were stored a large uncovered garbage can that contained garbage bags and a covered dumpster that contained debris protruding out from under the lid so that the cover failed to seal and completely cover the dumpster.

During an interview on 8/24/2020 at 9:15 am the Food Service Supervisor Employee E12 confirmed that the facility failed to maintain the outdoor refuse area in a sanitary condition which created the potential for rodent and pest infestation.

28 Pa Code: 207.2(a) Administrator's responsibility.
Previously cited: 2/19/19, 11/1/18, 9/18/18, 5/16/18, 3/30/18 2/18/18 and 1/16/18.








 Plan of Correction - To be completed: 10/06/2020

The Dumpster area in the rear of the building was cleaned up by the Maintenance staff. The unused smaller bins were removed.
Housekeeping staff or designee will make rounds of the dumpster holding containers and surrounding area to ensure that all garbage is inside the dumpster holding containers and the area around the garbage holding containers is maintained in a safe and clean order.
Audits of the area around the dumpster holding containers and the
area surrounding the dumpster holding containers will be completed 3 times a week for 4 weeks then weekly for 2 months Housekeeping staff or designee.
The Administrator or designee will educate the housekeeping staff to ensure that the doors to the garbage holding containers are closed and the surrounding area is free of excess trash.
The results of the audit will be reviewed by QAPI committee meeting for compliance for 3 months. The committee will determine compliance and the need for continued audits or additional action plans.

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 review of facility signage and policy, observations and staff interviews, it was determined that the facility failed to make certain that procedures were properly completed and consistently followed related to the prevention and mitigation of the spread of a virus (Screening process of visitors and employees).

Finding include:

A sign posted on the front door of the facility informed all staff and visitors that their temperatures were taken upon entrance into and exit from the facility.

The facility policy, "COVID-19" dated 3/10/20, indicated that what was known about the COVID-19 virus was that it was spread by person-to-person mainly between people who are within six feet of one another through respiratory droplets and that interventions were taken within the facility to prevent the spread of respiratory germs which included monitoring residents, staff and visitors upon entry to and exit from the facility and heightened surveillance activities were implement such as not sharing objects between people. The policy also noted that two separate forms were utilized: one when signing into the facility and another when signing out.

During an observation of the screening procedure upon entrance to the facility on 8/24/20, at 8:15 a.m. Activity Employee E8 took visitors' temperature and there was one pen being utilized by multiple persons to sign into the facility.

During an interview on 8/24/20, at 8:20 a.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) reported that this is the procedure the facility had been using, acknowledged the potential for spreading disease by one pen being utilized by multiple persons and confirmed the failure to effectively implement a procedure for the prevention and mitigation of the spread of a virus during the screening process.

28 Pa. Code: 201.14(a) Responsibility of licensee.
Previously cited 11/8/19.

28 Pa. Code: 201.18(b)(1) Management.
Previously cited 11/8/19

28 Pa. Code: 211.10(d) Resident care policies.
Previously cited 11/8/19.

28 Pa. Code: 211.12(d)(1)(3) Nursing services.
Previously cited 11/8/19.






 Plan of Correction - To be completed: 10/06/2020

The procedure for screening visitors and staff members upon entrance to the facility has been changed.
The updated procedure has eliminated the use of one pen by multiple persons. A facility staff member will take the visitors name and temperature and document on a log. The new procedure will mitigate and prevent the potential spread of a virus.
Infection control policy and procedures were updated.
Residents retested for covid-19, 8/21/2020 results returned negative.
The Director of Nursing or designee will audit / monitor the new procedure 3 times a week for 4 weeks then weekly for 2 months for infection control compliance. Any discrepancies will be reported to the Administrator for immediate follow up.
The results of the audit will be reviewed by QAPI committee meeting for compliance for 3 months. The committee will determine compliance and the need for continued audits or additional action plans.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:

Based on review of a facility specific document and facility policies, observations and staff interviews, it was determined that the facility failed to make certain that the procedure for house-supplied medications was followed during medication administration for two of eight residents (Resident R77 and R108), and failed to store medications under proper temperature controls in one of five medication room refrigerators (2nd floor medication room), or separately by route of administration and dated in two of seven medication carts (2nd and 3rd floor carts) and treatments were kept separated in the wound care cart.

Findings include:

The facility was granted a permanent exception on March 13, 2017, as related to their house-supplied medications. The exception noted that the facility utilized a list that detailed the names of all residents who were prescribed house-supplied medications, the list was received weekly from the pharmacy and listed the resident names and specified the house-supplied medications they received and the nurse would review and update the list for accuracy daily during medication pass.

The facility policy "House-Supplied (Floor Stock) Medications" dated 4/15/20, indicated that the floor stock medication list was posted in medication rooms and that the medications were kept in their original manufacturer's container.

The facility policy " Labeling of Medication Containers" dated 4/15/20, indicated that labels for each floor stock medication included all necessary information such as: the name and strength of the drug, the lot and control numbers, the expiration date, appropriate accessory and cautionary statements and directions for use.

Neither of the facility policies addressed the procedure for house-supplied medications as per the facility's permanent exception.

The facility policy "Storage of medications" dated 4/15/20, indicated medications requiring refrigeration are kept in a refrigerator at temperatures between 36 Fahrenheit (F) and 46 F. Orally administered medications are kept separate from externally used medications and treatments such as suppositories. When the original seal of a manufacturers container is broken the container or vial will be dated. Each residents medication shall be assigned to an individual cubicle, drawer or other holding area.

During an observation of a medication pass on 8/25/20, at 8:50 a.m. Licensed Practical Nurse (LPN) Employee E2
dispensed and administered the following house-supplied medications to Resident R108:
-Iron (supplement) 325 milligram (mg) tablet
-Fish oil 1,000 mg tablet
-Omeprazole (decreases stomach acid) 20 mg tablet

During an observation of a medication pass on 8/25/20, at 9:08 a.m. LPN Employee E2 dispensed and administered the following house-supplied medication to Resident R77:
-Senna (stool softener) 8.6 mg via gastrostomy tube.

There were no resident names on the bottles of iron and fish oil supplements, the Omeprazole and Senna and LPN Employee E2 did not reference a house-supplied medication list.

During an interview on 8/25/20, at 9:30 a.m. LPN Employee E2 reported not knowing anything about a house-supplied medication list and when the front of the medication binder was checked a house-supplied medication list, dated 8/25/20, was found however it was inaccurate and did not include the names of Resident R77 and R108.

During an interview on 8/25/20, at 9:35 a.m. Assistant Director of Nursing Employee E1 confirmed that the facility had an exception as related to the house-supplied medications and that the facility failed to make certain that the procedure for the house-supplied medications was followed by the nurses during medication administration.

During an observation of the facilities wound treatment cart on 8/25/20, at 8:05 a.m. dermoplast (topical anesthetic), wound cleanser, hydrogen peroxide, and ammonium lactate (lotion for dry skin) were observed to be clustered together in a drawer.

During an interview on 8/25/20, at 8:15 a.m. the facilities wound care Registered Nurse confirmed the above observation and confirmed that the facility clustered residents treatments in the same drawer, and failed to separate resident treatments.

During an observation of the second floor medication room refrigerator on 8/25/20, at 10:56 a.m. with the Director of Nursing (DON) the medication refrigerator thermometer indicated the temperature was 48 F. Stored inside the refrigerator was three bottles of lorazepam.

During an observation of the second floor medication cart on 8/25/20, at 11:00 a.m. with the DON three containers, one each of sodium bicarbonate (administered by mouth), guaifenesin (administered by mouth) and ibuprofen (administered by mouth) were stored in the same compartment as opened in use dulcolax suppositories (administered externally).

During an observation of the third floor medication cart on 8/25/20, at 11:15 a.m.with the DON the cart contained a container of valproic acid with manufacturers expiration date of March 3, 2022, the manufacturers seal was broken and the date the seal was broken was not written on the label.

During a second observation of the second floor medication room refrigerator on 8/25/20, at 12:40 p.m. with LPN Employee E15 the thermometer was observed to be placed in the freezer section and not in the refrigerated section with the lorazepam.

During a third observation of the second floor medication room refrigerator on 8/25/20, at 1:00 p.m. with LPN Employee E15 the temperature was observed to be 48 F.

During an interview on 8/27/20, at 11:00 a.m. the DON confirmed that the facility failed to store refrigerated medications at proper temperatures, separate by route, label with expiration date when opened, and separate treatments in the wound cart.

28 Pa. Code: 211.9(h)(k) Pharmacy services.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 11/8/19 and 10/8/19.



 Plan of Correction - To be completed: 10/06/2020

The facility was granted a permanent exception on March 13, 2017, as related to their house-supplied medications.
The Medical Director, Nursing Home Administrator, Director of Nursing have reviewed the Over the Counter exception and confirmed the policy.
The residents Over the counter list will be printed out every Monday on each floor and will be posted in medication rooms and copies placed on each medication cart for the RN/LPN to review before given medication.
The Director of Nursing or designee will re-educate the RNs / LPNs on the facility policy on the exception on over the counter medications.
The Director of Nursing/designee will perform an audit of the medication cart for the presence of the Over the Counter list 3 times a week for a month then weekly for 2 months. The results of the audit will be reviewed by QAPI committee meeting for compliance for 3 months. The committee will determine compliance and the need for continued audits or any additional action plan.

Medication Storage Refrigerator:
The refrigerator was replaced immediately after discovering the temperature was not in range. Pharmacy called and medications in the refrigerator were reviewed for safety.
The refrigerator temperature is checked daily on the 11-7, it was checked that day and reading was within range of 36-40 degrees that morning.
Refrigerator temperature monitoring will be be completed once on every shift.
The Director of Nursing or designee will re-educate staff RNs/LPNs on the proper temperatures of the refrigerators and what corrective actions should be done if out of range.
The Director of Nursing or designee will perform an audit of the refrigerator temperature log for compliance 3 times weekly for a month then weekly for 2 months.

The results of the audit will be reviewed by QAPI committee meeting for compliance for 3 months. The committee will determine compliance and the need for continued audits or any additional action plan.
Medication Carts:
The facility immediately removed the identified medication upon notification of being clustered together or not dated from the medication/treatment carts.
The facility conducted an audit of the facility medication/treatment carts and medication storage areas to ensure the appropriate labeling and dating of opened medication.
The Director of Nursing or designee re-educated the staff RNs/LPNs on the facility policy for labeling/dating and storage of medications.
The Director of Nursing or designee will perform audits of the medication cart for the proper labeling/dating and storage of medications 3 times a week for one month then weekly for 2 months.
The results of the audit will be reviewed by QAPI committee meeting for compliance for 3 months. The committee will determine compliance and the need for continued audits or any additional action plan.


483.10(g)(4)(i)-(vi) REQUIREMENT Required Notices and Contact Information: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.
483.10(g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including:
(i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes -
(A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section;
(B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act.
(C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and
(D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.
(ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.)
(iii) Information regarding Medicare and Medicaid eligibility and coverage;
(iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program;
(v) Contact information for the Medicaid Fraud Control Unit; and
(vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.
Observations:
Based on review of facility policy, observation, and staff interview it was determined that the facility failed to post the State complaint hotline contact information (name, address, e-mail, and phone number) for five out of five nursing units (2nd floor, 3rd floor, 4th floor, 5th floor, and 6th floor nursing units).


Findings include:

The facility "Resident Rights-Required Postings" policy, last reviewed April 15, 2020, indicated it is the policy of the facility to inform its residents in such a manner to acknowledge and respect resident rights. The facility must post a list of names, addresses, e-mail, and telephone numbers of all pertinent State agencies, the State survey agency, State licensure office, and the Office of the State Long-Term Care Ombudsman program. The facility must post a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation.

During an observation of the bulletin board located on the Fifth floor nursing unit on 8/24/20, at 11:30 a.m. the State complaint hotline number was not posted.

During an interview on 8/24/20, at 11:35 a.m. Activity Employee E8 confirmed that the State complaint hotline number was not posted on the Fifth floor nursing unit bulletin board.

During observations on 8/25/2020, with the Nursing Home Administrator (NHA), the sixth floor resident bulletin board was observed at 3:13 pm and did not include a phone number for the State complaint hotline.

During observations on 8/25/2020, the fourth floor resident bulletin board was observed at 3:18 pm and did not include a phone number for the State complaint hotline.

During observations on 8/25/2020, the third floor resident bulletin board was observed at 3:20 pm and did not include a phone number for the State complaint hotline.

During an interview on 8/25/2020 at 3:20 pm, the NHA confirmed that the facility failed to post the State complaint hotline in a prominent location for the third, fourth, and sixth floors as required.



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

28 Pa Code: 201.29 (a) Resident Rights.



 Plan of Correction - To be completed: 10/06/2020

Department of Heath Complaint hotline phone number and address has been posted on all floors in the common area by the Administrator or designee.
Residents will be educated at the next resident council meeting by the Administrator or designee that they have access to the Department of Heath complaint hotline contact information and where the postings are located.

For residents that do not attend resident council, they will be individually provided with the hotline number.

The Director of Nursing or designee will educate staff on the location of the Department of Health complaint hotline contact information and the right of accessibility by the residents.
The Director of Nursing or designee will monitor the presence of the postings on the 2nd, 3rd, 4th 5th and 6th floors 3 times a week for a month then weekly for 2 months. Any discrepancies will be reported to the Administrator for immediate follow up.
The results of the audit will be reviewed by QAPI committee meeting for compliance for 3 months. The committee will determine compliance and the need for continued audits or any additional plan of action.

211.10(b) LICENSURE Resident care policies.:State only Deficiency.
(b) The policies shall be reviewed at least annually and updated as necessary.
Observations:
Based on review of a facility specific document and facility policies, it was determined that the facility failed to make certain that all policies were updated to reflect what their current practices/procedures were related to house-supplied medications (House-supplied medication policies).

Findings include:

The facility was granted a permanent exception on March 13, 2017, as related to their house-supplied medications. The exception noted that the facility utilized a list that detailed the names of all residents who were prescribed house-supplied medications, the list was received weekly from the pharmacy and listed the resident names and specified the house-supplied medications they received and the nurse would review and update the list for accuracy daily during medication pass.

The facility policy "House-Supplied (Floor Stock) Medications" dated 4/15/20, indicated that the floor stock medication list was posted in medication rooms and that the medications were kept in their original manufacturer's container.

The facility policy "Labeling of Medication Containers" dated 4/15/20, indicated that labels for each floor stock medication included all necessary information such as: the name and strength of the drug, the lot and control numbers, the expiration date, appropriate accessory and cautionary statements and directions for use.

Neither of the facility policies addressed the procedure for house-supplied medications as per the facility's permanent exception.

During an interview on 8/25/20, at 9:35 a.m. Assistant Director of Nursing Employee E1 confirmed that the facility had an exception as related to the house-supplied medications and that the facility failed to update the policies to reflect what their current practices/procedures were related to house-supplied medications.



 Plan of Correction - To be completed: 10/06/2020

The facility was granted a permanent exception on March 13, 2017, as related to their house-supplied medications.
The facility update the policy and procedure book to include the use of the over the counter list and will reflect what the current practices/procedures were related to house-supplied medications.

The Director of Nursing or designee will re-educate the RNs / LPNs on the facility policy on the exception and the update to the policy and procedure related to the use of the Over the counter list.

Changes to the policy and procedure manual will be reviewed at the QAPI committee meeting.

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