Initial Comments:Based on the findings of an onsite unannounced follow-up survey completed 5/25/2023, Penn Home Health Inc. had not corrected the deficiencies cited under 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies. The deficiencies were cited as a result of a Medicare recertification survey completed 12/8/2022.
Plan of Correction:
484.55(b)(1) ELEMENT
5 calendar days after start of care
Name - Component - 00
The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care.
Observations:
Based on review of agency policies, medical records (MR), and staff (EMP) interview, the agency failed to ensure that staff completed a timely comprehensive assessment within five (5) days of start of care for one (1) of two (2) MR review for therapy services (MR2).
Findings included:
A review of MR2 conducted on 5/23/2023 at approximately 1:00 PM, the start of care was 4/19/2023 with a certification period of 4/19/2023 to 6/17/2023. The primary diagnosis was type 2 diabetes mellitus with diabetic polyneuropathy. Per the plan of care listed under section "Orders/Treatments Discipline Orders...Occupational Therapy to Assess and Evaluate 4/19/2023 through 4/26/2023,
Per MR2 "Occupational Therapy Visit Note...Date of Visit 4/25/2023...code OTO1 Evaluation Description OT Evaluation Visit..." EMP2 confirmed on 5/23/2023 at 1:04 PM that the date the OT conducted the initial visit was 4/25/2023. The surveyor requested from EMP2 any documentation of patient contact within the five (5) day period from the start of care date, no documentation was provided.
An interview was conducted with the administrator on 5/23/2023 at approximately 2:30 PM which confirmed the above findings.
Plan of Correction:The OT evaluation was completed within the timeframe of the physicians order but was not in the time frame of the regulation period of 5 days. The evaluation was completed, therefore was not able to be corrected and redone.
All patient's OT evaluations will be reviewed to ensure that they were completed in their 5 day time frame that they were ordered in.
Education will be performed to OT on completing comprehensive evaluations within the 5 day period that they are ordered to be completed in or document the reason why they could not be completed. Then obtain a new verbal order for a new comprehensive evaluation.
Clinical manager / designee will audit OT comprehensive evaluations monthly x 2.
484.55(c)(5) ELEMENT
A review of all current medications
Name - Component - 00
A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.
Observations:
Based on a review of agency policy and procedure, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile to ensure review of all medications the patient was taking for three (3) of four (4) MR reviews conducted (MR2, MR3 and MR4).
Findings included:
Review of agency policy and procedures on 12/7/2022 at approximately 11:50 AM revealed, "MEDICATION PROFILE...PURPOSE To define the use of the medication profile in evaluating a patient's medication regimen, including over-the-counter (OTC) medications, nutrition supplements, herbal remedies, vitamins and minerals. POLICY Patient receiving medications administered by the organization will have a current, accurate a medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. PROCEDURE 1. Upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen. 2. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of new medication. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicate drug therapy, and noncompliance with drug therapy...5. Based on review of the medication profile as sell as the written material, changes in the plan of care may be required. 6. Any conclusion and findings of patient medication use or monitoring should be communicated to the pharmacist, when appropriate, and other clinicians..."
A chart review was conducted for MR2 on 5/23/2023 at approximately 11:20 AM, the start of care was 4/19/2023 with a certification period of 4/19/2023 to 6/17/2023. The primary diagnosis was type 2 diabetes mellitus with diabetic polyneuropathy. The agency "Medication Profile" (print date 5/23/2023) was compared to the facilities (MAR).
The following medication was not listed on the agency medication profile.
"FLUTICASONE SPR 50MCG...Date Written 12-May-2023..."
A chart review was conducted for MR3 on 5/23/2023 at approximately 11:30 AM, a review of the plan of care listed the start of care 4/18/2023 for a current certification period starting 4/18/2023 and ending 6/16/2023. The primary diagnosis was Displaced trimalleolar fracture of left lower leg, subsequent encounter for closed fracture with routine healing The agency "Medication Profile" (print date 5/23/2023) was compared to the facilities (MAR).
The following one medication was not listed on the facilities MAR:
"START DATE...4/18/2023...MEDICATION...Lovenox 40mg/0.4 mL Injectable solution; Inject 40 milligrams subcutaneously once a day..."
A chart review was conducted for MR4 on at approximately 11:50 AM, a review of the plan of care listed the start of care 3/24/2023 for a current certification period starting 3/24/2023 and ending 5/22/2023. The primary diagnosis was COVID-19. The agency "Medication Profile" (print date 5/23/2023) was compared to the facilities document "View All Orders Report." (Print Date: 5/23/2023).
The following medication was listed with different dosages orders:
Facility: "Escitalopram Oxalate Oral Tablet 20 MG...Give 20 mg by mouth one time a day for depression...Order Date 05/03/2023."
Agency: "START DATE...3/24/2023 escitalopram 10 mg oral tablet; Take 1 tab(s) orally once a day..."
An interview was conducted with the administrator on 5/23/2023 at approximately 2:30 PM which confirmed the above findings.
Plan of Correction:Reviewed medication profiles for MR2, MR3, MR4.
Corrected all medications to identify any duplicate therapies, inaccurate medications, potentially adverse effects, and to ensure that medication profiles matched both the agency and PCH.
Clinical manager or designee will review all MAR's from patients in PCH's to ensure that medication profiles from agency match the MAR's from the PCH's.
Educate staff to review all medication profiles to add/delete medications and verify with the MD so that profiles always match.
Onsite education was provided to all RN's and LPN's on medication reviews on MARs for all facilities that our patients reside in, to be completed at every visit to ensure that all medications are added / deleted and verified with the MD so that profiles always match.
Clinical Manage / designee will audit MARs and agency medication profiles monthly x 2.
484.60(d) STANDARD
Coordination of Care
Name - Component - 00
Standard: Coordination of care.
The HHA must:
Observations:
Based on review of the agency policies and procedures, medical records (MR) and staff (EMP) interview, the agency failed to coordinate care with facilities for patient care for three (3) of four (4) MR reviews conducted (MR2, MR3 and MR4).
Findings included:
Review of agency policy and procedures on 12/7/2022 at approximately 11:50 AM revealed, "MEDICATION PRODILE...PURPOSE To define the use of the medication profile in evaluating a patient's medication regimen, including over-the-counter (OTC) medications, nutrition supplements, herbal remedies, vitamins and minerals. POLICY Patient receiving medications administered by the organization will have a current, accurate a medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. PROCEDURE 1. Upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen. 2. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of new medication. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicate drug therapy, and noncompliance with drug therapy...5. Based on review of the medication profile as sell as the written material, changes in the plan of care may be required. 6. Any conclusion and findings of patient medication use or monitoring should be communicated to the pharmacist, when appropriate, and other clinicians..."
Review of agency policy and procedures on 12/13/2022 at approximately 1:00 PM revealed, "THE PLAN OF CARE...PURPOSE To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. POLICY A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the Home Health program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process...PROCEDURE...11. As needed, the patient and family/caregiver will receive written instructions regarding treatments or aspects of care that will be the responsibility of the patient and family/caregiver to provide or follow through with...13. All Appropriate Home Health staff will have access to the plan of care..."
Review of agency policy and procedures on 12/13/2022 at approximately 1:00 PM revealed, "Job Title/Position Registered Nurse (RN) Reports To: Clinical Supervisor JOB DESCRIPTION SUMMARY The registered nurse plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities. ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES Patient Care...8. Provides health care instructions to the patient as appropriate per assessment and plan of care...10. Acts as Case Manager when assigned by Clinical Supervisor and assumes responsibility to coordinate patient care for assigned caseload...Communication...3. Communicates with community health-related persons to coordinate the care plan..."
A chart review was conducted for MR2 on 5/23/2023 at approximately 11:20 AM, the start of care was 4/19/2023 with a certification period of 4/19/2023 to 6/17/2023. The primary diagnosis was type 2 diabetes mellitus with diabetic polyneuropathy. The agency "Medication Profile" (print date 5/23/2023) was compared to the facilities (MAR).
The following medication was not listed on the agency medication profile.
"FLUTICASONE SPR 50MCG...Date Written 12-May-2023..."
A chart review was conducted for MR3 on 5/23/2023 at approximately 11:30 AM, a review of the plan of care listed the start of care 4/18/2023 for a current certification period starting 4/18/2023 and ending 6/16/2023. The primary diagnosis was Displaced trimalleolar fracture of left lower leg, subsequent encounter for closed fracture with routine healing The agency "Medication Profile" (print date 5/23/2023) was compared to the facilities (MAR).
The following one medication was not listed on the facilities MAR:
"START DATE...4/18/2023...MEDICATION...Lovenox 40mg/0.4 mL Injectable solution; Inject 40 milligrams subcutaneously once a day..."
A chart review was conducted for MR4 on at approximately 11:50 AM, a review of the plan of care listed the start of care 3/24/2023 for a current certification period starting 3/24/2023 and ending 5/22/2023. The primary diagnosis was COVID-19. The agency "Medication Profile" (print date 5/23/2023) was compared to the facilities document "View All Orders Report." (Print Date: 5/23/2023).
The following medication was listed with different dosages orders:
Facility: "Escitalopram Oxalate Oral Tablet 20 MG...Give 20 mg by mouth one time a day for depression...Order Date 05/03/2023."
Agency: "START DATE...3/24/2023 escitalopram 10 mg oral tablet; Take 1 tab(s) orally once a day..."
An interview was conducted with the administrator on 5/23/2023 at approximately 2:30 PM which confirmed the above findings.
Plan of Correction:MR2, MR3, MR4 - all MARs were updated for each change to reflect current medication, to include all new and discontinued medications.
Review all MAR's for medications for all patients in PCH to ensure profiles match agency profiles for medications.
Educate staff on reviewing all MARs at PCH for always adding/ deleting medications so that the PCH medication profiles match agency profiles. Making sure that verification is completed with the MD.
Onsite education was provided to all RN's and LPN's on medication review on MARs for all facilities that our patients reside in, to be completed at every visiti to ensure that all medications are accurate and corrected/verified with the MD so that the profiles always match both the agency and facility.
Clinical manager or designee will audit PCH MARs with agency medication profile for accuracy with medications/allergies monthly x 3
Initial Comments:Based on the findings of an onsite unannounced follow-up survey completed 5/25/2023, Penn Home Health Inc. had not corrected the deficiency cited under PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies. The deficiency was cited as a result of a State relicense survey completed 12/8/2022.
Plan of Correction:
601.32(b) REQUIREMENT
DUTIES OF THE REGISTERED NURSE
Name - Component - 00
601.32(b) Duties of the Registered
Nurse. The registered nurse:
(i) makes the initial evaluation
visit,
(ii) regularly reevaluates the
patient's nursing needs,
(iii) initiates the plan of treatment
and necessary revisions,
(iv) provides those services
requiring substantial specialized
nursing skill,
(v) initiates appropriate
preventive and rehabilitative nursing
procedures,
(vi) prepares clinical and progress
notes,
(vii) coordinates services, and
(viii) informs the physician and other
personnel of changes in the patient's
condition and needs, counsels the
patient and family in meeting nursing
and related needs, participates in
inservice programs, and supervises and
teaches other nursing personnel.
Observations:
Based on review of the agency policies and procedures, medical records (MR), job descriptions and staff (EMP) interview, the agency failed to maintain an accurate medication profile to ensure review of all medications the patient was taking for three (3) of four (4) MR's reviewed from a facility (MR2, MR3 and MR4).
Findings included:
Review of agency policy and procedures on 5/24/2023 at approximately 1:45 PM revealed, "THE PLAN OF CARE...PURPOSE To ensure that an individualized plan of care is completed that complies with accepted standards of care3 and regulatory issues. POLICY A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the Home Health program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process...PROCEDURE...11. As needed, the patient and family/caregiver will receive written instructions regarding treatments or aspects of care that will be the responsibility of the patient and family/caregiver to provide or follow through with...13. All Appropriate Home Health staff will have access to the plan of care..."
Review of agency policy and procedures on 5/24/2023 at approximately 1:45 PM revealed, "MEDICATION PRODILE...PURPOSE To define the use of the medication profile in evaluating a patient's medication regimen, including over-the-counter (OTC) medications, nutrition supplements, herbal remedies, vitamins and minerals. POLICY Patient receiving medications administered by the organization will have a current, accurate a medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. PROCEDURE 1. Upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen. 2. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of new medication...The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicate drug therapy, and noncompliance with drug therapy...5. Based on review of the medication profile as sell as the written material, changes in the plan of care may be required. 6. Any conclusion and findings of patient medication use, or monitoring should be communicated to the pharmacist, when appropriate, and other clinicians..."
Review of agency policy and procedures on 5/24/2023 at approximately 1:45 PM revealed, "Job Title/Position Registered Nurse (RN) Reports To: Clinical Supervisor JOB DESCRIPTION SUMMARY The registered nurse plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities. ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES Patient Care...8. Provides health care instructions to the patient as appropriate per assessment and plan of care...10. Acts as Case Manager when assigned by Clinical Supervisor and assumes responsibility to coordinate patient care for assigned caseload...Communication...3. Communicates with community health-related persons to coordinate the care plan..."
A chart review was conducted for MR2 on 5/23/2023 at approximately 11:20 AM, the start of care was 4/19/2023 with a certification period of 4/19/2023 to 6/17/2023. The primary diagnosis was type 2 diabetes mellitus with diabetic polyneuropathy. The agency "Medication Profile" (print date 5/23/2023) was compared to the facilities (MAR).
The following medication was not listed on the agency medication profile.
"FLUTICASONE SPR 50MCG...Date Written 12-May-2023..."
A chart review was conducted for MR3 on 5/23/2023 at approximately 11:30 AM, a review of the plan of care listed the start of care 4/18/2023 for a current certification period starting 4/18/2023 and ending 6/16/2023. The primary diagnosis was Displaced trimalleolar fracture of left lower leg, subsequent encounter for closed fracture with routine healing The agency "Medication Profile" (print date 5/23/2023) was compared to the facilities (MAR).
The following one medication was not listed on the facilities MAR:
"START DATE...4/18/2023...MEDICATION...Lovenox 40mg/0.4 mL Injectable solution; Inject 40 milligrams subcutaneously once a day..."
A chart review was conducted for MR4 on at approximately 11:50 AM, a review of the plan of care listed the start of care 3/24/2023 for a current certification period starting 3/24/2023 and ending 5/22/2023. The primary diagnosis was COVID-19. The agency "Medication Profile" (print date 5/23/2023) was compared to the facilities document "View All Orders Report." (Print Date: 5/23/2023).
The following medication was listed with different dosages orders:
Facility: "Escitalopram Oxalate Oral Tablet 20 MG...Give 20 mg by mouth one time a day for depression...Order Date 05/03/2023."
Agency: "START DATE...3/24/2023 escitalopram 10 mg oral tablet; Take 1 tab(s) orally once a day..."
An interview was conducted with the administrator on 5/23/2023 at approximately 2:30 PM which confirmed the above findings.
Plan of Correction:All medications were corrected on MR2, MR3, MR4 to make sure all duplications and inaccuracies were corrected and the PCH MAR and agency medication profile matched.
Review MARs from patients in PCH with medication profiles from the agency to ensure accuracy and that they are both correct and match.
Educate staff to check MAR at PCH with agency medication profile when patients are on hold, return from the hospital, for any additions or discontinuations, have doctor appointments, and always make changes accordingly so both the MAR and medication profile match.
Onsite education was provided to all RN's and LPN's on medication review on MAR's for all facilities that our patients reside in, to be completed at every visit to ensure that all medications are added or deleted and verified with the MD so that profiles always match.
Clinical manager or designee with audit MAR and agency med profile monthly x2
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