State revokes certificate of compliance for Heritage Springs Memory Care in Lewisburg

Aug. 7—LEWISBURG — The state Department of Human Services revoked the certificate of compliance for the Heritage Springs Memory Care in Lewisburg following five new violations in its latest inspection report.

In two documents totaling 13 pages dated Aug. 4 to Heritage Springs Memory Care, at 327 Farley Circle, the state Department of Human Services (DHS) detailed that Heritage did not have enough staff on specific shifts, paperwork was not properly completed, a new resident did not have a cognitive screening in a timely manner and a threat from one resident to another went unreported.

DHS issued a first provisional license to the facility, which is valid until Feb. 4, 2024. If the violations are not corrected within five calendar days of the receipt of the letter, the state intends to assess fines. Three of the types of violations carry a $150 per day fine and a fourth type carries a $90 per day fine.

"All violations specified on the LIS (Licensing Inspection Summary) must be corrected by the dates specific on the report and continued compliance with 55 Pa. Code Ch. 2600 (relating to personal care homes) must be maintained," Juliet Marsala, the deputy secretary of Office of Long-Term Living, wrote in the letters. "Failure to implement the plan of correction or failure to maintain compliance may result in a revocation of the license."

The five violations stemmed from licensing inspections on April 12, April 13, May 3, May 9, May 18, June 6, June 15 and June 27. These are in addition to 24 previous violations in the last three inspections from April, February and December.

The department will conduct an on-site inspection at the mandated correction date within 20 calendar days of Aug. 4, Marsala wrote.

"If one or more violations are not fully corrected and full compliance with the regulation has not been achieved, you will periodically receive invoices from the Department's Bureau of Human Services Licensing with payment instructions," said Marsala. "The fines will continue to accumulate until the violation is fully corrected and full compliance with the regulation has been achieved."

The fines are based on the number of residents.

Two employees of Heritage Springs Memory Care were accused last month of abusing elderly residents at the Union County facility between December and April. Madison Laine Cox, 18, of Pinchtown Road, Montgomery, and a 17-year-old male juvenile allegedly posed with patients in the shower or on the toilet, took pictures of patients who had defecated themselves or had fallen to the ground and took videos of themselves demeaning or harassing individuals, according to court documents filed by the Buffalo Valley Regional Police Department.

The five new violations are not related to the criminal investigation or accusations of elder abuse.

Tammy Speece, the executive director at Heritage Springs, did not respond to an email from The Daily Item seeking comment on this report.

Staffing

Heritage is licensed for a capacity of 64. At the time of its inspection, it was serving 30 residents ages 60 years and older and a total daily staff of 60, according to the report.

In one violation, the home had a census of 31 residents on June 5, all of whom have mobility needs due to residing in a secure dementia home. The home's total number of direct care hours provided was 49. The home's required minimum number of direct care hours for that date was 62, according to the report.

Heritage claimed that staff called off and did not show up for shifts, resulting in being below the required hours.

The facility used maintenance, administrative and housekeeping employees to assist with transporting residents and doing laundry, but those hours did not count, according to Heritage.

"Also, one of our residents has a caregiver for three days a week during day shift as well as seven days a week overnight, which is not counted in the total as well," according to Heritage. "However, executive director and resident care director will ensure staffing levels are maintained at all times."

In another violation, Heritage "currently serves 30 residents in a secured setting," according to the report. "Two of these residents need assistance of two, one resident needs assistance of one to transfer out of bed, six use wheelchairs."

The report said all of the patients need special care to evacuate during an emergency.

"Once the residents have evacuated, one staff person must remain with the residents at all times when not inside the locked units," the report said.

On a date that was blacked out in the report, a "staff person worked from 6:25 p.m. to 6:13 a.m. In the event of an emergency, the home does not have enough staff to meet the needs of the residents," according to the report.

As part of the plan of correction, Heritage "has always had at least two staff members scheduled for night shift," according to Heritage.

On this particular night, the "med tech in charge felt it was quiet" so the second staff member was permitted to go home, "indicating that all was good," according to Heritage.

"Executive director stressed the importance of having adequate staff on each shift in case of an emergency," according to Heritage. "Since 6/21/23, we now have three staff scheduled for third shift to meet regulations. Executive director along with resident care director will review schedule daily to make sure adequate staff is scheduled and if not, utilize the services of an outside agency."

Documentation, reporting

A new resident's documentation of the medical evaluation (DME) form did not indicate the resident required a secure dementia unit. Another DME was not completed prior to the resident's admission to the home, according to the report.

Heritage's plan of correction noted that the DEM was completed prior to admission by the family physician. The resident chose the in-house physician, which required a second DME to be completed.

The resident care director and executive director will "double check all paperwork for admissions to ensure all areas are completed prior to admission," according to the plan of correction.

A new resident did not have a cognitive screening completed in a timely manner, according to the report.

As part of the plan of correction, Heritage wrote that the resident chose an in-house physician, who could not sign the paperwork until someone whose name was blacked out returned from vacation.

Heritage did not report in a timely manner to the state that one resident threatened another resident. The dates were blacked out in the report.

The incident was not reported, according to Heritage in the report, because there were not any injuries.

Heritage's previous violations included the following: Some staff members did not have up-to-date training or the required number of training hours; injuries resulting from residents falling were not reported in a timely manner; fire drill safety procedures were inadequate; and numerous documents were missing key pieces of patient information.

Heritage has the right to appeal through a hearing before the Bureau of Hearings and Appeals.

Upcoming court hearing

Cox has been charged with 17 misdemeanor counts of abuse of a care-dependent person.

The charges were filed by Buffalo Valley Regional Police Patrolman Gary V. Heckman in the Lewisburg office of District Judge Jeffrey Rowe.

Cox is scheduled for a preliminary hearing at 9 a.m. Aug. 24 in front of Rowe.