Failure to Document Resident/Representative Invitations to Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to document that residents or their representatives were invited to participate in care conferences for two of five reviewed residents. Facility policies titled “Care Planning - Interdisciplinary Team” and “Care Plans, Comprehensive [NAME]-Centered,” both dated 4/14/25, state that residents, families, and/or legal representatives are encouraged to participate in care plan development and revisions, and that residents are informed of their right to participate and provided advance notice of care planning conferences. For one resident, admitted on an unspecified date with diagnoses including hypertension, diabetes, and post-surgical amputation care needs, the plan of care dated 1/14/26 included discharge planning to home with family support and home health services. A care conference note dated 12/23/25 stated that a care conference was held and that the resident and family declined the invite, but review of the clinical and paper records did not show documentation that the resident or family member had actually been invited. For a second resident, admitted on an unspecified date with diagnoses including heart failure, COPD, and a seizure disorder, a care conference note dated 12/2/25 similarly documented that a care conference was held and that the resident and family declined the invite. However, review of this resident’s clinical record also failed to show documentation that the resident or family member had been invited to the care conference. During an interview, a family member of the first resident reported that the facility did not provide information related to Medicare payment limitations and allowed time in the facility and stated that he was never invited to a care plan conference. In a separate interview, the DON confirmed that the facility failed to document the invitation of the resident or their representative to care conference meetings for two of five residents reviewed, in violation of cited Pennsylvania regulatory codes regarding resident rights, resident care policies, and nursing services.
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