Huntington Hills Center for Health and Rehabilitation
January 3, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 3, 2018
Corrected date: January 26, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that a comprehensive person-centered care plan (CCP) for each resident was developed to meet the resident's current needs. This was evident in 1 (Resident # 45) of 2 residents reviewed for assistive devices. Specifically, Resident #45 required bilateral hand rolls as per therapy evaluations and recommendations. The resident was observed on two occasions without the gauze hand rolls in place. The use of the hand rolls was not identified on the Comprehensive Care Plan nor on the care instructions provided to the Certified Nursing Assistant (CNA). The finding is: Resident # 45 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment with both short term and long term memory problems. The MDS documented the resident required total assistance of staff for activities of daily living in hygiene, transferring, eating and dressing. The MDS further documented the resident had functional limitation in Range of Motion (ROM) to one upper extremity. A Rehabilitation Evaluation dated 12/4/2017 documented the resident was non-ambulatory, required assist of two staff members for transfer and had Right (R) shoulder, R elbow and R wrist limitations. The Left (L) shoulder, L elbow and the L wrist also had limitations. The bilateral hands were observed partially open. A Rehabilitation evaluation done on 12/5/2017 documented a follow up screen was performed. The resident was issued bilateral gauze rolls to both hands to maintain the current ROM to both hands and to prevent further contractures. The evaluation documented that nursing was aware and in agreement. The resident was observed on 12/21/17 at 11:38 AM without the hand rolls in place. The resident's hands were shut with the fingers curled, pressing against the palms of both hands. On 12/22/17 at 10 AM, Resident # 45 was observed without hand rolls in place. There were two hand rolls observed laying near each other on the resident's chest while the resident was reclined in a Geri- Chair. The resident is unable to move the bilateral upper extremities on command due to cognitive deficits and contractures. The CNA was interviewed on 12/22/17 at 10:15 AM and stated she placed the hand rolls on the resident's chest and intended to apply them later. When asked why the resident did not have hand rolls in place on 12/21/17, the CNA stated she could not remember if she placed the hand rolls on the resident on 12/21/17. The resident's Comprehensive Care Plan (CCP) was reviewed and as of 12/28/17 there was no CCP developed for the use of the hand rolls. The CCP addressing the resident's self-care performance deficit related to Activity Intolerance, Dementia, Functional Limitations, Impaired Balance, Limited Mobility, Limited Range of Motion (ROM), and Neurological Deficits documented that the resident had contractures of upper and lower extremities. Interventions included to provide skin care every shift and as needed (PRN), to keep clean and prevent skin breakdown. The CCP did not identify the use of bilateral hand gauze rolls to prevent skin breakdown and/or contractures. The current Kardex, dated (MONTH) (YEAR), which provides instructions for the CNA regarding specific resident care needs, did not include instructions related to the use of the hand rolls. The Charge Registered Nurse (RN) was interviewed at 12/28/17 at 4:00 PM and stated that it was an error that a CCP was not developed to address the resident's hand rolls. The Director of Nursing Services (DNS) was interviewed on 12/28/17 at 3:45 PM and stated a CCP should have been in place for the resident's hand rolls. The surveyor reported to the DNS that on 12/21/17 and 12/22/17, the resident was observed without hand rolls in place. The DNS stated that there should have been hand rolls in place. The surveyor asked how would staff know to apply the hand rolls if hand rolls were not documented on the CNA Kardex. The DNS stated that staff apply hand rolls to contracted hands. She further stated the Kardex was updated today (12/28/17) to include hand rolls to both hands. The Physical Therapist (PT) was interviewed on 1/2/18 at 2:45 PM and stated the resident requires bilateral hand rolls to prevent skin breakdown to both hands and to prevent contractures. The PT stated the resident would open both hands on command on assessment on 12/4/17 and has a behavior that causes her to clinch her hands. The PT further stated if the resident was not wearing the hand rolls the PT would expect to be notified. 415.11(c)(1)

Plan of Correction: ApprovedJanuary 15, 2018

? What corrective action will be accomplished for those residents found to have been affected by the deficient practice.
Resident # 45 had a recommendation for hand rolls that was not on the care plan or CNA Kardex. The bilateral hand rolls were immediately added to the care plan and CNA kardex on 12/28/17.
? How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
All residents that are evaluated by therapy where therapy has made a recommendation have the potential to be affected. The rehab manager will run a report on all recommendations made in the past 3 months. The list will be reviewed and an audit will be completed to make sure that the recommendations are in the care plan and the CNA Kardex. All residents are evaluated every 3 months by therapy.
? What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur.
Anytime that a therapist issues a device or makes a recommendation for a resident/patient, the recommendation will be in writing. There will be 2 copies. One copy will go to the unit nurse and the other copy will go to the DNS or ADNS in her absence. The licensed nurse will document recommendations on the care plan and the CNA Kardex. All therapists and licensed nurses will be educated regarding the new process.
? How the corrective actions will be monitored to ensure the deficient practice will not recur, (QA).
The DNS will do an audit weekly of all recommendations to ensure that all assistive devices are on the care plan and in the CNA Kardex.
? The date for correction and the title of the person responsible for correction of each deficiency:
Person responsible: DNS / ADNS
Date: 1/26/2018

Standard Life Safety Code Citations

DEVELOPMENT OF COMMUNICATION PLAN

REGULATION: (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 3, 2018
Corrected date: January 26, 2018

Citation Details

Based on documentation review and staff interview, the facility's Emergency Preparedness plan did not comply with Federal, State and local laws. The twenty four hour, seven day a week contacts were unassigned in the Health Provider Network (HPN) Communications Directory. The findings are: On 12/21/17 between 11:00am- 3:00pm during the recertification survey, review of the facility's Communications Directory on the HPN revealed that the four roles under the twenty four hour, seven day a week contacts were unassigned. This was contrary to the requirements of 10NYCRR 400.10 in that at minimum, twenty-four hour, seven day a week contacts for emergency communication and alerts must be designated by each facility in the HPN Communications Directory. In an interview on 12/21/17 at approximately 2:10pm, the Administrator stated that he will try to put in the contact information. 10NYCRR 400.10

Plan of Correction: ApprovedFebruary 7, 2018

E029.
Residents affected: None
Potential Residents Affected: All
Measures put in place to correct deficient practice: HPN Communications Directory for 24 hour 7 day a week contacts was updated on 1/26/2018 by Administrator using Coordinator's Update Tool under section: Organizational Offices, Emergency Offices. All required fields were completed.
How will corrective action be monitored: Administrator will review HPN MANAGE ROLE ASSIGNMENTS and ORGANIZATIONAL OFFICES weekly to assure all roles are appropriately filled with current staff of facility. A monitoring form will be maintained with a weekly verification of all proper emergency roles are identified in the HPN for a period of 3 months, then the verification will be done monthly.
Person responsible: Administrator. 2/7/2018

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 3, 2018
Corrected date: January 26, 2018

Citation Details

Based on documentation review and staff interview, the facility's Emergency Preparedness plan did not address the role of the facility under a waiver declared by the Secretary. The facility lacked a policy. The findings are: On 12/21/17 between 11:00am- 3:00pm during the recertification survey, review of the facility's Emergency Preparedness plan revealed that they lacked a policy regarding the role of the facility under a waiver declared by the Secretary. Facilities must develop and implement policies and procedures that describe its role in providing care at alternate care sites during emergencies. Specifically, the facility's role in emergencies under a waiver declared by the Secretary, in accordance with section 1135 of the Act. An example, including but not limited to, licensure for physicians or others to provide services in the affected state. In an interview on 12/21/17 at approximately 2:00pm, the Administrator stated that they do not have a policy and procedure for the role of the facility under a waiver declared by the Secretary, and that he would add one.

Plan of Correction: ApprovedFebruary 7, 2018

E026.
Residents affected by deficient practice: None
Other residents having the potential to be affected: All
Measures put into place to ensure deficient practice does not recur: 1135 Waiver request was submitted to CMS by Administrator on 12/27/17 per instructions on CMS website for 1135 Waiver (ROPHIDSC@cms.hhs.gov) NYS DOH Environmentalist copied on CMS submission. Administrator will monitor HPN for any emergency notifications requiring facility waiver submission to state of federal government. Assistant Administrator will provide back up for HPN review. HPN review will be documented on a weekly verification form to assure any emergency communications have been received and acted upon.
Person Responsible: Administrator. 2/7/2017