Pennsylvania Department of Health
ACCELERATE SKILLED NURSING AND REHABILITATION PHILADELPHIA
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ACCELERATE SKILLED NURSING AND REHABILITATION PHILADELPHIA
Inspection Results For:

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ACCELERATE SKILLED NURSING AND REHABILITATION PHILADELPHIA - 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 August 23, 2024, it was determined that Accelerate Skilled Nursing and Rehabilitaion Philadelphia, 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 related to the health portion of the survey process.

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

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.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Plan of Correction - To be completed: 10/09/2024

Residents 5, 6, 7, and 8 were assessed and did not identify an ill effect from being in dialysis on 8/23/24. The facility along with the dialysis staff will determine alternative treatment plans at a sister facility while the facility permits the unit to be repaired.
Initial audits by the nurse of Residents 5, 6, 7, and 8 that had received dialysis at the facility were assessed to determine any ill effects from the elevation in temperature.
NHA or designee will provide education to the Maintenance Director to ensure that the temperature remains within the 72-75 degrees. If determined outside the range, an alternative plan will be set to provide services at our sister dialysis den.
The NHA or designee will conduct random weekly audits x 3 weeks then monthly x 2 of the dialysis den's temperature on days that dialysis is provided. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee x 3 monthly.

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:

Based on staff interviews, review of facility documentation, and the state survey reporting system, it was determined that the facility failed to ensure that allegations of abuse and neglect were reported to the state survey agency for 4 out of 4 residents reviewed (Resident R1, R2, R3 and R4).

Findings include:

Review of the facility policy, "Abuse Prohibition, " with a revision date of October 2, 2022 indicated that immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property, no later than 2 hours after the allegation is made, if the event results in serious bodily injury, or within 24 hours if the event does not result in serious bodily injury.

Continued review of the policy indicated that the facility would initiate an investigation within 24 hours of an allegation of abuse, protect patients from further harm during an investigation, and report findings of all completed investigations within 5 working days to the state survey agency.

Review of the resident's August 2024 physician orders indicated that Resident R1 was admitted into the facility on August 8, 2024 with diagnosis that included the following: osteoarthritis (a degenerative joint disease resulting in pain and stiffness); polyneuropathy (a condition in which an individual's peripheral nerves are damaged such as the face, arms and legs); hypertension (high blood pressure) and diarrhea.

Review of the resident Grievance/Concern book revealed a grievance submitted on behalf of Resident R1 on August 14, 2024, stating that he had been sitting in feces all day and no one would help him get cleaned. The resident reported in his grievance that the morning nurse aides told him that he asked too late and had to wait for the next shift.

Review of the August 2024 physician orders for Resident R2 indicated that she was admitted into the facility on July 16, 2024 with diagnosis that included the following: hypokalemia (low blood potassium levels); glaucoma (a group of eye diseases that damages the optic making it difficult to see clearly); atrial fibrillation (a condition of the heart that is characterized by an irregular and often rapid heartbeat); hypertension (high blood pressure); diabetes (a condition that affects your blood sugar levels and can cause serious complications) and difficulty in walking.

Review of the resident Grievance/Concern book revealed a grievance submitted by the daughter of Resident R2 dated July 22, 2024. The grievance stated that the resident did not receive care on July 20, 2024 and July 21, 2024, and that she had the same clothes on that she had on Friday. The grievance also stated that the resident's teeth were not brushed. Continued review of the grievance indicated a concern with a named nurse aide on Friday who allegedly threw the resident's wet pats on the dresser, and left the resident on a wet sheet. The grievance also alleged that the named nurse aide was confrontational and said that she was working by herself. The grievance also documented a concern with a 2nd named nurse aide who allegedly told Resident R2 to urinate in her diaper, and instructed that resident not to take it off because she (the 2nd named nurse aide) was working by herself. The grievance also alleged that a 3rd named nursing staff employee "does nothing at night."

Review of the August 2024 physician orders for Resident R3 indicated that the resident was admitted into the facility on July 25, 2024 with diagnosis that included the following: asthma (a lung disorder lung disorder that causes shortness of breath, wheezing and coughing); kidney failure (a condition when one or both kidneys no longer work on their own); heart failure (a condition in which the heart muscles can't pump blood as well as they should); respiratory failure (a life threatening condition that affects a persons breathing and oxygen levels), and morbid obesity.

Review of the resident Grievance/Concern book revealed a grievance submitted on behalf of the resident dated July 28, 2024. The grievence indicated a concern that included allegations related to an incident with the nurse aide at 2:00 a.m. on Saturday night. The allegation reported in the grievence was that the nurse aide assisted the resident to the commode, appeared disgusted with her, and tossed the resident's feet on the bed ....did not straighten her up, and walked out.

Review of the August 2024 physician orders for Resident R4 indicated that the resident was admitted into the facility on June 24, 2024 with diagnosis that included the following: cerebral infarction (a stroke); diabetes (a group of disease that affect how the body uses blood sugar); dementia (a group of symptoms affecting an individual's memory, thinking and social abilities), and chronic obstructive pulmonary disease (COPD-a chronic lung disease that makes breathing difficult).

Review of the resident Grievance/Concern book revealed a grievance submitted on behalf of the resident dated August 14, 2024 which alleged that the aides for all shifts are not helping the resident use the toilet, and are telling her to go in her brief. The grievance form also stated that as a result of the above, the resident had to take herself to the bathroom because no one would help.

Review of the reporting system for the facility's state survey agency did not show evidence that the state survey agency was notified, and the resutlts of any investigation was reported regarding the referenced allegations.

During a discussion with the Director of Nurse (DON) and the Regional Nurse on August 23, 2024, at 11:15 a.m. regarding the above referenced allegations, it was discussed that the above referenced concerns were not reported to the state survey agency to rule about abuse/neglect, as required.

28 Pa. Code 51.3 (f) Notification

28 Pa. Code 51.3 (g)(6) Notification

28 Pa. Code 211.12 (d)(5) Nursing Services

Plan of Correction - To be completed: 10/09/2024

Residents 1, 2, and 3 are discharged from the facility. Resident 4 remains at the facility and their grievance will be reported to the Department of Health.
Initial audit to be conducted by the NHA or designee of the last 30 days of grievances to determine if current residents reported any allegation of abuse or neglect. If any allegations through the grievance are identified the facility will report to the Department of Health.
NPE or designee will provide education to current employees on ensuring that alleged violations of abuse or neglect are reported immediately, but no later than 2 hours after the allegation if it results in serious bodily injury, or reported within 24 hrs if no injury is identified to the Department of Health.
DON or designee will conduct weekly audits of grievances x 4 weeks then monthly x 2 on possible allegations that require reporting to the Department of Health. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee x 3 monthly.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:

Based on staff interviews and review of facility documentation, it was determined that the facility failed to conduct a complete and thorough investigation regarding allegations of abuse/neglect for 4 out of 4 residents reviewed (Resident R1, R2, R3 and R4).

Findings include:

Review of the facility policy, "Abuse Prohibition, " with a revision date of October 2, 2022 indicated that immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property no later than 2 hours after the allegation is made if the event results in serious bodily injury or within 24 hours if the event does not result in serious bodily injury.

Continued review of the policy indicated that the facility would initiate an investigation within 24 hours of an allegation of abuse, protect patients from further harm during an investigation, and report findings of all completed investigations within 5 working days to the State Survey Agency.

The policy also indicated that the investigation would be thoroughly documented, and that documentation of witnessed interviews would be included.

Review of the resident's August 2024 physician orders indicated that Resident R1 was admitted into the facility on August 8, 2024 with diagnoses of osteoarthritis (a degenerative joint disease resulting in pain and stiffness); polyneuropathy (a condition in which an individual's peripheral nerves are damaged such as the face, arms and legs); hypertension (high blood pressure) and diarrhea.

Review of the resident Grievance/Concern book revealed a grievance submitted on behalf of Resident R1 on August 14, 2024, stating that he had been sitting in feces all day and no one would help him get cleaned. The resident reported in his grievance that the morning nurse aides told him that he asked too late and had to wait for the next shift.

A typed statement dated August 14, 2024 and signed by the Director of Nursing (DON) indicated that she was notified that the resident needed assistance with incontinence care, went up to his floor and made sure that staff provided it.

No additional information was provided regarding the investigation related to the allegations reported on Resident R1's behalf

Review of the August 2024 physician orders for Resident R2 indicated that she was admitted into the facility on July 16, 2024 with diagnoses of hypokalemia (low blood potassium levels); glaucoma (a group of eye diseases that damages the optic making it difficult to see clearly); atrial fibrillation (a condition of the heart that is characterized by an irregular and often rapid heartbeat); hypertension (high blood pressure); diabetes (a condition that affects your blood sugar levels and can cause serious complications) and difficulty in walking.

Review of the resident Grievance/Concern book revealed a grievance submitted by the daughter of Resident R2 dated July 22, 2024. The grievance stated that the resident did not receive care on July 20, 2024 and July 21, 2024, and that she had the same clothes on that she had on Friday. The grievance also stated that the resident's teeth were not brushed. Continued review of the grievance indicated a concern with a named nurse aide on Friday who allegedly threw the resident's wet pads on the dresser, and left the resident on a wet sheet. The grievance also alleged that the named nurse aide was confrontational and said that she was working by herself. The grievance also documented a concern with a 2nd named nurse aide who allegedly told Resident R2 to urinate in her diaper, and instructed that resident not to take it off because she (the 2nd named nurse aide) was working by herself. The grievance also alleged that a 3rd named nursing staff employee "does nothing at night."

A typed, undated statement with the first and last name of the 2nd named aide was obtained and it was noted that she was assigned to Resident R2 on July 21, 2024. The nurse aide reported that outside of asking the Resident R2 and her roommate about their morning care, the best time to assist them with it, giving them breakfast, lunch, water, and checking on them throughout the day, the 2nd named nurse aide reported that she did not have any other interactions with them. She also reported that a co-worker answered the call bell for Resident R2 and went in to assist Resident R2 with either using the bathroom or assisting the resident with changing herself.

No additional information was provided regarding the investigation related to the allegations reported on Resident R2's behalf.

Review of the August 2024 physician orders for Resident R3 indicated that the resident was admitted into the facility on July 25, 2024 with diagnoses of asthma (a lung disorder lung disorder that causes shortness of breath, wheezing and coughing); kidney failure (a condition when one or both kidneys no longer work on their own); heart failure (a condition in which the heart muscles can't pump blood as well as they should); respiratory failure (a life threatening condition that affects a persons breathing and oxygen levels), and morbid obesity.

Review of the resident Grievance/Concern book revealed a grievance submitted on behalf of the resident dated July 28, 2024. The grievence indicated a concern that included allegations related to an incident with the nurse aide at 2:00 a.m. on Saturday night. The allegation reported in the grievence was that the nurse aide assisted the resident to the commode, appeared disgusted with her, and tossed the resident's feet on the bed ....did not straighten her up, and walked out. There was also a concern related to missing medication.

The grievence noted that the resident's missing medication was adminstered.

No additional information was provided regarding the investigation related to the other allegations reported on Resident R3's.

Review of the August 2024 physician orders for Resident R4 indicated that the resident was admitted into the facility on June 24, 2024 with diagnoses of cerebral infarction (a stroke); diabetes (a group of disease that affect how the body uses blood sugar); dementia (a group of symptoms affecting an individual's memory, thinking and social abilities), and chronic obstructive pulmonary disease (COPD-a chronic lung disease that makes breathing difficult).

Review of the resident Grievance/Concern book revealed a grievance submitted on behalf of the resident dated August 14, 2024 which alleged that the aides for all shifts are not helping the resident use the toilet, and are telling her to go in her brief. The grievance form also stated that as a result of the above, the resident had to take herself to the bathroom because no one would help.

No additional information was provided regarding the investigation related to the other allegations reported on Resident R3's.

Continued review of the Grievance/Concerns for Resident R1, R2, R3 and R4 regarding allegations of not receiving appropriate care and services by facility staff did not include any evidence provided by the facility that a complete and thorough investigation was conducted to ensure that abuse/neglect was ruled out.

During a discussion with the Director of Nurse (DON) and the Regional Nurse on August 23, 2024, at 11:15 a.m. regarding the above referenced allegations, it was discussed that there was no evidence that a complete and through investigation was completed by the facility to rule out abuse/neglect.

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 201.18(b)(1)(3) Management

Plan of Correction - To be completed: 10/09/2024

Residents 1, 2, and 3 are discharged from the facility. Resident 4 remains at the facility and their grievance will be reported to the Department of Health.
An initial audit will be conducted by the NHA or designee of the facility's reported grievances to determine if any required a report to the Department of Health for an allegation of abuse/neglect and to determine if a thorough investigation was completed timely.. If any are identified as a possible reportable to the Department of Health one will be reported
NPE or designee will provide education to current employees on ensuring that alleged violations of abuse or neglect are reported immediately to the Supervisor, NHA, and DON.
DON or designee will conduct weekly audits of grievances x 4 weeks then monthly x 2 on possible allegations that require reporting to the Department of Health to include through investigation was completed within 5 days. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee x 3 monthly.

483.25(l) REQUIREMENT Dialysis:

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.

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on staff interviews, and review of clinical records, it was determined that the facility failed to ensure that residents received care and services for dialysis treatment that was consistent with professional standards of practice for dialysis care for 2 out of 4 residents reviewed for dialysis treatment (Resident R6 and R8).

Findings include:

Review of the facility policy, "Dialysis: Hemodialysis (HD)-Communication and Documentation" with a revision date of June 15, 2022 indicated that the facility staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after the patient receives the treatments. The policy also indicated that upon return to the facility, a licensed nurse will review the dialysis center communication form related to the resident treatment, evaluate and observe the patient, and complete the post-hemodialysis treatment section on the "Hemodiaysis Comunication Record."

Review of the August 2024 orders indicated that the resident was admitted into the facility on March 26, 2024, with diagnosis that included hypertension (high blood pressure); heart failure (a condition where the heart muscle can't pump blood as well as it should); diabetes (a group of disease that affect how the body uses blood sugar) and dependence on renal dialysis.

Review of nursing notes from March 2024 through August 2024 indicated that the resident was receiving dialysis treatments on Mondays, Wednesdays, and Fridays.
Review of the August 2024 physician orders for Resident R6 did not show evidence that the resident had a physician's order for dialysis treatment.

Continued review of the resident's clinical record also did not include a person-centered plan of care for dialysis treatment to ensure that goals and interventions related to this care area are developed and implemented to meet the resident's needs.

Review of the clinical records for Resident R6 did not include any evidence that the resident's condition was monitored post dialysis treatment for complications (e.g. blood pressure, temperature weight), in addition to assessing, observing and also documenting the care of the resident dialysis access site (the site that is utilized to reach the individual's blood during dialysis treatment) post dialysis treatment.

During an interview with the dialysis center Regional Operations Manager (DE2) on August 26, 2024, at 1:14 p.m. she confirmed that Resident R6 had been receiving onsite dialysis treatment at the facility since March 27, 2024.

Review of the August 2024 physician orders for Resident R8 indicted that the resident was admitted into the facility on August 7, 2024 with diagnosis of human Immunodeficiency virus (HIV); hypotension (low blood pressure); dysphagia (difficulty swallowing); malnutrition (lack of sufficient nutrients in the body; end state renal disease (the gradual loss of kidney function that reaches an advanced state), and dependence on renal dialysis.

Review of nursing notes from August7, 2024 through August 23, 2024 indicated that the resident was receiving dialysis treatments on Mondays, Wednesdays, and Fridays.

Review of the August 2024 physician orders for Resident R6 did not show evidence that the resident had a physician's order for dialysis treatment.

Continued review of the resident's clinical record also did not include a person-centered plan of care for dialysis treatment to ensure that goals and interventions related to this care area are developed and implemented to meet the residents needs.
Review of the clinical records for Resident R6 did not include any evidence that the resident's condition was monitored post dialysis treatment for complications (e.g. blood pressure, temperature weight), in addition to assessing, observing, and also documenting the care of the resident dialysis access site (the site that is utilized to reach the individual's blood during dialysis treatment) post dialysis treatment.

During an interview with the dialysis center Regional Operations Manager (DE2) on August 26, 2024, at 1:14 p.m. she confirmed that Resident R8 had been receiving onsite dialysis treatment at the facility since August 9, 2024.

During an interview with the Director of Nursing (DON) and the Regional Nurse on August 23, 2024, at 6:00 p.m. it was discussed that the clinical record for Resident R6 and R8 did not show evidence of physician orders for dialysis treatment, a care plan for dialysis treatment, or any evidence that Residents R6 and R8 are being monitored and assessed by nursing staff post dialysis treatment.

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

28 Pa Code 211.12(d)(3) Nursing services

Plan of Correction - To be completed: 10/09/2024

Resident 6 is still present in the facility and Resident 8 was discharged 9/1/2024. A review of the last 2 weeks for Resident 6 to ensure that a nurse reviewed with a signature. If a record from dialysis not reviewed will be obtained and findings reported to the physician services with a signature of a nurse after the review. Resident 6's clinical record update with a person-centered plan of care for dialysis treatment.
An initial audit will be completed by the DON or designee of current residents receiving dialysis for completion of their Dialysis HD-Communication and Documentation form
NPE or designee will provide education to current license nursing staff on ensuring the Dialysis HD- Communication and Documentation is complete pre and post dialysis for current dialysis residents. Licensed Nursing staff will ensure that plan of care is completed for residents' receiving dialysis.
DON or designee will conduct weekly audits of grievances x 4 weeks then monthly x 2 on current resident's completed Dialysis HD-Communication and Documentation forms are completed pre and post dialysis treatment with a signature from a nurse. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee x 3 monthly

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 10/09/2024

1,2) Nurse aide staffing ratios will be reviewed for the last 7 days to evaluate if nurse aide ratios are met.
3) Nursing admin and scheduler will be re-educated on new July 1 nurse staffing and PPD requirements.
4) Weekly audit of nurse aid ratios will be conducted for 4 weeks then monthly x 2 by NHA/designee to ensure nurse aid ratios are met. Tracking and trends to be submitted to the QAPI committee

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of nursing time schedules, punch reports and staff interviews, it was determined that the facility failed to provide a minimum of 3.20 hours of direct nursing care per resident on 4 of 21 days reviewed (August 17, 18, 19, and 20).

Findings include:

Review of facility census data, punch reports and nursing time schedules revealed that on August 17, 2024, the facility census was 122, and a total of 382.57 direct nursing staff hours were provided, which equaled 3.14 hours of direct nursing care per resident.

Review of facility census data, punch reports and nursing time schedules revealed that on August 18, 2024, the facility census was 123, and a total of 332.30 direct nursing staff hours were provided, which equaled 2.70 hours of direct nursing care per resident.

Review of facility census data, punch reports and nursing time schedules revealed that on August 19, 2024, the facility census was 125, and a total of 339.70 direct nursing staff hours were provided, which equaled 2.72 hours of direct nursing care per resident.

Review of facility census data, punch reports and nursing time schedules revealed that on August 20, 2024, the facility census was 126, and a total of 378.40 direct nursing staff hours were provided, which equaled 3.00 hours of direct nursing care per resident.

Plan of Correction - To be completed: 10/09/2024

1,2) HPPD will be reviewed for the last 7 days to evaluate if the state minimum PPD of 3.2 is met.
3) Nursing admin and scheduler will be re-educated on new July 1 nurse staffing and PPD requirements.
4) Weekly audit of HPPD will be conducted for 4 weeks then monthly x 2 by NHA/designee to ensure minimal HPPD is met. Tracking and trends to be submitted to the QAPI committee.

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