Pennsylvania Department of Health
EMBASSY OF HEARTHSIDE
Patient Care Inspection Results

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EMBASSY OF HEARTHSIDE
Inspection Results For:

There are  213 surveys for this facility. Please select a date to view the survey results.

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EMBASSY OF HEARTHSIDE - 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 February 15, 2024, it was determined that Embassy of Hearthside, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations


 Plan of Correction:


483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.15(d) Notice of bed-hold policy and return-

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

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

Based on select facility policy and procedures, clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative received written notice of the facility's bed hold policy at the time of transfer for two of four residents reviewed for hospitalizations (Residents 3 and CR1 ).

Findings include:

The current facility policy entitled, "Transfer/Bed Hold/Return Policy," revealed that the facility provides the resident and responsible representative with notice of its bed hold policy upon admission and at the time of transfer or therapeutic leave from the facility to ensure continuity of care.

Clinical record review for Resident 3 revealed that he was transferred to the hospital on January 18, 2024, for behavioral issues. A progress note dated January 18, 2024, at 3:08 PM revealed that the facility bed-hold agreement was printed and sent with the resident to the hospital per policy.

Review of Resident 3's quarterly Minimum Data Set (MDS, an assessment completed by the facility, at intervals, to determine the resident's care needs) assessment dated December 12, 2023, revealed that he had a BIMS (Brief interview of mental status) score of 2, indicating he was mentally severely impaired.

The Director of Nursing confirmed that Resident 3 would not understand the bed-hold notice and that his responsible party should have been notified and provided a copy of the bed-hold policy within 24 hours, on February 15, 2024, at 2:30 PM.

The facility failed to provide written notice of their bed hold policy to Resident 3's responsible party within 24 hours of his transfer to the hospital.

Closed clinical record review for Resident CR1 revealed that the facility completed an MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) on October 2, 2023, and indicated that the resident was comatose (of or in a state of deep unconsciousness for a prolonged or indefinite period, especially as a result of severe injury or illness.)

Resident CR1 was transferred to the hospital on October 28, 2023, and January 16, 2024, after they had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident's responsible party upon transfer out to the hospital.

The surveyor reviewed the above information for during an interview with the Nursing Home Administrator and Director of Nursing on February 15, 2024, at 2:36 PM.

28 Pa. Code 201.14(a) Responsibility of licensee


 Plan of Correction - To be completed: 03/11/2024

1. The facility cannot retroactively correct the lack of bed hold policy on notification to responsible parties for resident 3 and CR1.
2.DON/designee will complete an audit of any other residents transferred out to the hospital in the last 7 days will be completed to identify other residents to whom a bed hold notification was not provided to the capable resident or responsible party.
3. The facility DON/Designee will review and update the current policy as needed.
Administration, admissions, and licensed nursing staff will be educated on revisions and Policy.
4. DON/designee will complete an audit of transfers to the hospital for the next two months to ensure that the bed hold notification was provided to the capable resident or responsible party of incapable residents. Results of the Audit will be reviewed at the facilities QAPI meeting.

483.15(e)(1)(2) REQUIREMENT Permitting Residents to Return to Facility:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.15(e)(1) Permitting residents to return to facility.
A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following.
(i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident-
(A) Requires the services provided by the facility; and
(B) Is eligible for Medicare skilled nursing facility services or Medicaid
nursing facility services.
(ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.

§483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.
Observations:

Based on facility policy, review of clinical records, and staff interview, it was determined that the facility failed to ensure that a resident who was transferred from the facility with the expectation of returning was permitted to return, had met the specific requirements for a facility-initiated discharge, and/or provided evidence that the facility was not able to meet the resident's needs for one of four residents reviewed (Resident CR1).

Findings included:

The current facility policy entitled "Transfer/Bed-Hold/Return Policy," revealed that the resident may resume residence in the facility following therapeutic leave or hospitalization if the resident required services provided by the facility and the resident was eligible for Medicaid nursing facility services or agrees to pay privately for these services.

Closed clinical record review revealed that Resident CR1 was admitted on September 26, 2023, with diagnoses of a tracheostomy (surgically placed throat breathing tube), enteral tube feed (surgically placed stomach feeding tube), pressure ulcers, and nontraumatic subarachnoid hemorrhage (brain bleed).

The facility transferred Resident CR1 on January 25, 2024, to the hospital at the request of his family member for a concern of respiratory distress.

Further review revealed that the hospital attempted to transfer Resident CR1 back to the facility on January 25, 2024. Hospital documentation dated January 26, 2024, revealed that the hospital readmitted him due to the "lack of caregiver." Resident CR1 "was brought back to the (emergency department) via (emergency transport) after (the facility) refused to take the patient back due to lack of bed availability ... refused to accept him and demanded that he be take back to the (emergency department) for placement at another facility."

Nursing documentation dated January 26, 2024, at 11:49 AM revealed the facility "called (Resident CR1's) mother and made her aware we are not able to accept (Resident CR1) back at the (facility). This is due to Medicaid pending status, no bed hold in place, and the facility feels this is [not] the appropriate facility for (Resident CR1's) or family's needs."

Interview with the Nursing Home Administrator on February 15, 2024, at 2:30 PM confirmed that Resident CR1 was Medicaid Pending status, which the facility considered as a private pay resident, until Medicaid status was confirmed on February 5, 2024.

Review of the facility's roster (form CMS-802, to identify specific resident diagnoses and/or concerns) revealed that the facility had other residents admitted with the same and/or similar diagnoses as Resident CR1.

The resident's clinical record contained no physician documentation of the specific reasons why the resident's symptoms could not be treated at the facility and documented evidence of the facility's attempts to meet this resident's needs and maintain the resident's safety and the safety of others. There was no documentation of the level of services provided at the receiving facility, which could not be provided at the long-term care facility.

There was no indication that the facility had evaluated the resident's current treatment plan and the resident's response to that plan while they were hospitalized to determine if the resident may be permitted to return to the long-term care facility.

Interview with the Director of Nursing (DON) on February 15, 2024, at 2:30 PM acknowledged that the facility failed to explain the specific reasons for Resident CR1's discharge but speculated that it was due to Resident CR1's family members actions, threats, and verbal and physical aggression while at the facility and emails and/or voicemails sent to the DON, the facility's medical director, and nurse practitioner. The DON voiced concern that Resident CR1's family would continue to threaten, abuse, and display aggression towards facility and contracted staff if readmitted to the facility.

There was no physician documentation in Resident CR1's clinical record regarding the circumstances surrounding the resident's discharge or why the facility was unable to meet the resident's needs at the time they were ready to be readmitted to the facility from the hospital.

Cross Refer F625

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

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

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


 Plan of Correction - To be completed: 03/11/2024

1. The facility cannot retroactively go back and readmit CR1. CR1 was not readmitted to the facility.
2. To Ensure other residents were not affected by the deficient practice an audit of readmissions of the past 30 days will be completed by the DON or designee.
3. Regional nurse of designee will conduct education to the IDT Members: DON, Administrator, ADON, Social Service Director, Business Office Manager, and Nursing Supervisors on discharge/transfer behold and readmission procedures; and F-tag 626 requirement. All new staff will be trained of this procedure during orientation.
4. Social Service /Administrator will audit all discharges to the hospital or LOA, and readmissions to ensure that all residents that discharged were allowed to return (offered a bed hold) per our Bed Hold policy. This will be done once a week for 1 month, then twice a month for 1 month, then 1 a month for 1 month. Results will be reviewed at QAPI meeting.



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