The following is from a 10/22 letter to Gracedale Administrator Michelle Morton from the state DOH. Any plan of correction submitted by the county should include the termination of its administrator.
Representatives of the Division of Nursing Care Facilities conducted a Revisit and Abbreviated Survey on October 20, 2026 to determine if your facility meets the requirements to participate in the federal certification program. All references to regulatory requirements contained in this letter are found in Title 42 CFR Part 483, Subpart B, Requirements for Long Term Care, and the 28 Pa. Code.
Based on the findings of this revisit, it was determined that your facility failed to correct the identified deficiencies, whereas continuing and/or new areas of noncompliance with the following participating requirements were identified:
F580 42 CFR §483.10(g)(14) Notification of Changes-New
F689 42 CFR §483.25(d) Accidents – Continuing – D
State Tag 1040 Responsibility of Licensee – New
The enforcement cycle start date is 09/10/2026.
If you do not correct the cited deficiencies within 90 days from the enforcement cycle start date, the Centers for Medicare and Medicaid Services and the state Medicaid agency must deny payments for new admissions. A remedy of a civil money penalty and/or directed in-servicing may be imposed. Additionally, we will recommend that your provider agreement be terminated six months from the enforcement cycle start date. Remedies already imposed for this enforcement cycle remain in effect. [Emphasis added by blogger].
You must submit your plan of correction electronically. The deficiencies will be available for review and development of your plan of correction on October 23, 2026. This plan must be available for our review on the Department of Health Facility Site at https://sais.health.pa.gov/commonpoc/Login/Login.aspx, by November 1, 2026. If the deficiencies are not available on October 23, 2026, please notify the field office. Failure to submit an acceptable plan of correction within the required time frame may result in the recommendation of the imposition of additional remedies.
Your plan of correction must contain the following:
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? How the corrective action will be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established?
Dates of when the corrective action will be completed.
If your plan of correction fails to contain these components for each deficiency cited, it will not be accepted. The specific target dates that you identify for your facility to achieve correction should reasonably reflect your facility's concern for the health and safety of your residents in relation to the deficiencies cited. If we conclude that your date of presumed compliance does not meet these criteria, it will not be accepted. The latest date identified for the completion of corrective actions will be accepted as the facility's allegation of compliance.
If we determine that subsequent to the date of presumed compliance identified by your facility that you have failed to achieve and maintain substantial compliance, additional remedies may be imposed.
Please note that this notice does not constitute formal notice of imposition of alternative remedies or termination of your provider agreement. Should the Centers for Medicare & Medicaid Services determine that termination or any other remedy is warranted, they will provide you with a separate formal notification of that determination.
The remainder of the letter provides informal dispute options.
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