Gracedale Had Two Serious Deficiencies in September and Failed to Notify NorCo Council

The long-awaited first-ever meeting of the Gracedale Oversight Committee was finally conducted yesterday afternoon. Though there are only four members, all of  NorCo Council, with the exception of Jeff Warren, were present. This heavy attendance is what'll happen when an Executive proposes a 43.5% tax hike and wants $12 million to go to Gracedale. 

Chair Kelly Keegan, who voted against establishing a Gracedale Oversight Committee, explained yesterday why she waited so long to call a meeting. She said she wanted to give Tom Carson, the newly appointed Director of the newly created Continuum of Care department, some time to familiarize himself with his new role. She said she'd take responsibility for the delay, and I can accept her reasoning after watching him yesterday. I'd say he even needs more time.

It was a very lengthy meeting and I will provide more detail in a separate post. But for now, I want to focus on two September inspections that resulted in G-level deficiencies — a classification described as involving actual harm to a resident. We'll learn more about them when the state Department of Health (DOH) posts its surveys. There was also a third, less serious, deficiency.

At a meeting in early February, Council member Dave Holland requested that County Council be immediately notified whenever DOH visits Gracedale because there is a 41-day lag between when a visit occurs and when it is posted online. He was assured that Council would be notified, but that never happened. 

Holland: "So you're telling me you had a survey on September 10 and there was a G?

Administrator Michelle Morton: "Correct."

Holland: "That's the first time this County Council is hearing that. Does anyone else have that information?"

Morton: "I believe that was sent in." 

Holland: "I'm telling you No. Whose responsibility is it to notify this Council when we have surveys because that did not happen? Anybody in the room? Anybody? Whose responsibility is it to do that?"

At this point, Executive Tara Zrinski said that function would have been up to the Human Services Director but now belongs to Carson. She apologized that she failed to make that duty clear to him.

This communication failure is significant because Gracedale remains on a Provisional II license. Pennsylvania records identify Gracedale as operating under that provisional status, following deficiencies that resulted in the downgrade.

As miffed as he was about the failure to notify Council of two serious deficiencies, Holland said the more serious issue was the new G-level deficiencies and what it could mean for Gracedale's provisional license. He had been encouraged that Gracedale might be moving toward getting out of provisional status, but that new G-level deficiencies could make that more difficult.

Zrinski acknowledged that losing the license was theoretically possible but argued that the latest incident was different from previous problems and that the appropriate response was to correct the problems rather than assume the facility would fail. "We are not going to lose this license," she flatly insisted. She said remained optimistic.

Council member Theresa Fadem was less optimistic. "I support optimism, but what's going to happen if we lose this license? Why are we being asked to fund another $12 million? I don't understand what is going on here. We're throwing money at a problem and we could just lose Gracedale. What is happening"

Zrinski rejected the notion that the county was simply "throwing $12 million" at Gracedale. She said the $12 million represents a budgeted county contribution based on what the county wants Gracedale to become, rather than what the facility looks like today.

She downplayed the G-level deficiencies saying "they are not as horrific as you think. We are not going to lose this license." She argued Gracedale only gets more attention because of a critical Grand Jury report. She also blamed agency nurses, claiming, "We need our eyes on people. That's how things like this happen."

Fadem remained unpersuaded. "How do we expect to attract more people to Gracedale when we keep doing the same thing over and over again and expect different results? Isn't that what somebody called the definition of insanity?"

Zrinski: "I do understand the definition of insanity." She then went on to say that other nursing homes have problems, too, referring to an incident at Moravian Hall Square. But Fadem noted that Gracedale, unlike Moravian Hall Square, is a publicly run facility. Zrinski then said she is putting out fires daily.

Council member Keegan, who is a nurse, told Zrinski that she would be sure to keep her eyes on patients with histories of problems. She said she wants to hear that every single employee is staring at the residents to ensure they don't fall, they don't choke or have other issues that can be prevented. Zrinski sarcastically suggested bubble wrap, but no one laughed "We want to hear that employees are taking extra care because this is serious," said Keegan.

Zrinski then got emotional. "Things can happen in a second. And when they do, you think, 'I should have been watching." And you blame yourself. You can't think that all of us sitting here today haven't thought, 'Damn it. We failed again.' because we do. That goes through our heads. And we're trying so hard. This is not easy."

She then returned to her seat.

This emotional exchange indicates that Gracedale's problems are beginning to take a toll on Zrinski, who does seem intent on keeping a poor administrator and unwilling to look into other publicly run nursing homes. 

The next Gracedale Oversight Committee will be December 2 at 4 pm.

I will report on other aspects of the meeting tomorrow.