QA Investigation Results

Pennsylvania Department of Health
COMMUNITY HOME HEALTH CARE, INC.
Health Inspection Results
COMMUNITY HOME HEALTH CARE, INC.
Health Inspection Results For:


There are  10 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an unannounced on-site home health Medicare re-certification and state re-licensure survey conducted between 4/2/19 through 4/9/19, Community Home Health Care, Inc. was found to be not in compliance with the requirements of 42 CFR, Part 484, Subpart B and C, Conditions of Participation: Home Health Agencies.











Plan of Correction:




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 upon review of agency policy, job descriptions, medical records (MR), and interview with president (EMP #1), agency failed to ensure the Registered Nurse (RN) completed a review of all medications currently taken during each home visit for seven (7) out of twenty-five (25) MR reviewed. (MR # 7, MR #9, MR # 10, MR# 11, MR #15, MR #22, MR #25) .

Findings included:

Review of agency policy titled " Contents of Plan of Care" on 4/2/19 between approximately 10:00 AM-12:00 PM , stated " The plan, shall include.... " medications and treatments"

Policy titled " Clinical Initial Assessment" stated " Comprehensive review of Medications that the patient is currently taking as well as instructions regarding name, dose, purpose, schedule, adverse reactions, side effects, drug allergies, incompatible medications/foods."

Policy titled " Plan of Care Review" stated " when a significant change in condition... new change orders are added..."

Job description for Staff Nurse/Case Manager stated " (2) Develops and implements a comprehensive goal focused, care plan.." (15) Informs the Supervising Nurse of patient services provided and ended and any changes in the Plan of Care"

Review of MR on 4/2/19 between approximately 12:15 PM-3:00 PM; 4/4/19 between 9:00 AM-11:00 AM and 12:30 PM -1:00 PM; 4/5/19 between 9:15 AM-12:00 PM and 12:30 PM-5:00 PM revealed:

MR # 7, SOC 2/27/19; nighty-two (92) year old male with primary diagnosis of hypertensive heart and chronic kidney disease with heart failure, chronic kidney disease stage 3 chronic combined systolic and diastolic (congestive) heart failure, old heart attach, chronic atrial fibrillation chronic obstructive pulmonary disease atherosclerotic heart disease of native coronary artery
The Certification and Plan of Care, 2/27/19-4/27/19.
Physician's order, " coumadin as ordered".
Does not list the dose, route, frequency, purpose, schedule, adverse reactions, side effects.
Order, " hold coumadin as ordered ".
Does not list the specific order parameters for when to hold and when to administer in addition to not listing dose, route, frequency, purpose, schedule, adverse reactions, side effects.
Order," hold medications as ordered".
Does not list the specific order parameters for when to hold and when to administer in addition to not listing dose, route, frequency, purpose, schedule, adverse reactions, side effects.
Order," medications as ordered".
Does not list the specific order parameters for when to administer in addition to not listing the specific medication, dose, route, frequency, purpose, schedule, adverse reactions, side effects.
Order, " pt/inr checkced as ordered".
Does not list the specific order for PT/ INR testing, how often the PT/ INR is to be taken, what parameters to notify physician.

MR # 9, SOC 10/26/18; seventy-seven (77) year old female with primary diagnosis of general epilepsy rheumatoid arthritis with rheumatoid factor fibromyalgia history of falling, encounter for issue of repeat prescription
The Certification and Plan of Care, 2/23/19-4/23/19, failed to include nursing orders for Subcutaneous (SQ) injection Medication order " Enbrel \ \ solution for injection subcutaneous \ qw \ " this order does not list the dose to be administered.

MR # 10, SOC 3/16/19; sixty-three (63) year old female with primary diagnosis of encounter for adjustment and management of peripherally inserted central catheter (picc) line encounter for issue of repeat prescription abscess of intestine perforation of intestine kidney stone, essential hypertension gastro-esophageal reflux disease
The Certification and Plan of Care, 3/16/19-5/14/19, failed to include complete IV medication order including:
the order " Ertapenem \ 1G/100 ML" \ does not list dose, frequency, route to be administered, purpose, schedule, adverse reactions, side effects.


MR # 11, SOC 12/31/18; eighty-five (85) year old male with primary diagnosis of respiratory failure pneumonia, dependent on supplemental oxygen, vascular dementia epilepsy prosthetic heart valve The Certification and Plan of Care, 3/1/19-4/29/19, failed to include complete medication orders including:
" Iron 325 mg qd no route of administration listed, purpose, schedule, adverse reactions, side effects.
patient on continuous oxygen and oxygen was not documented on medication section of certification and plan of care nor was the dose, route, frequency order present.



MR # 15, SOC 2/4/19; ninety (90) year old female with primary diagnosis of hemiplegia a stroke, aphasia difficulty walking, falling, chronic pain syndrome essential primary hypertension anxiety disorder
The Certification and Plan of Care dated 2/4/19-4/4/19. The patient was admitted to the hospital on 2/18/19 and was not discharged from the hospial until 4/1/19, six (6) weeks later, when a Resumption of Care (ROC) skilled nursing visit was conducted. The agency failed to obtain or show evidence of physician orders including an updated medication list upon discharge from hospital.

MR # 22, SOC 1/20/18; fifty-one (51) year old female with primary diagnosis of encounter for change or removal of surgical wound dressing, non pressure chronic ulcer lower limb, lymphedema pain in right leg, morbid obesity, personal history of other venous thrombosis and embolism osteoarthritis
The Certification and Plan of Care was 10/28/18-12/26/18 with medications listed:
" Citalopram \ 40 mg daily" no route listed.
"Coumadin \ 3 mg tablet every other day" no route listed.
"Diltiazem \ 60 mg twicw daily" no route listed.
"gabapentin \ 100 mg twice daily" no route listed.


. The patient was admitted to the hospital on 11/25/18 and was discharged from the hospital on 11/30/18 ( six (6) days) later with agency failing to obtain or show evidence of physician orders, including an updated medication list, upon resuming care and services.
Patient was readmitted to the hospital on 12/2/18 and discharged from the hospital on 12/8/18 (six (6) days) later with agency failing to obtain or show evidence of physician orders, including an updated medication list, upon resuming care and services.


MR # 25, SOC 3/22/19; eighty-seven (87) year old female with primary diagnosis of encounter for adjustment and management of peripherally inserted central line catheter, encounter for issue of repeat prescription, pneumonia sepsis chronic respiratory failure dependent on supplemental oxygen, type 2 diabetes
The Certification and Plan of Care, 3/22/19-5/20/19, failed to include:
complete IV medication order including:
the order " Ceftriaxone \ 2G/50 ML" \ solution for injection intravenous qd \ does not list dose to be administered, purpose, schedule, adverse reactions, side effects.


Interview with EMP # 1 on 4/8/19 between approximately 11:30 AM-12:30 PM confirmed above findings.













Plan of Correction:

G 0536 Review Of All Current Medications.
Elements Detailing How Deficiency will be Corrected:
An In-service will be conducted by the Administrator/supervising nurse on 5/9/2019 with all staff re: the absolute need to comply with COP 484.55(c)(5). A review of the Agency policy related to this standard will be covered with all professional staff members. Items reviewed during this in-service will included the need to provide a comprehensive review of all medications to assess for potential adverse effects; drug reactions; including ineffective drug therapy; significant side effects; significant drug interactions; duplicate drug therapy; and non-compliance with drugs being taken.

Standard will be read during this meeting with emphasis on the need for nursing to complete this medication reconciliation for all patients. RN's and Therapists will be instructed to review all medications in the home (both prescription and non-prescription). The clinician shall consider each medication the patient is currently taking for possible side effects and the list in its entirety for potential drug interactions. Staff will review the current agency policy for compliance with the standard.

In the case of therapy only cases, the therapist will be required to submit a list of patient medications collected during the comprehensive assessment. A nurse at the agency will review and contact the physician, if necessary.

Staff will be instructed to receive individualized orders at required timeframes-i.e. resumption of care; recertification; etc., and to assure orders include specific parameters are set for medications that are frequently changing -such as insulin, Coumadin etc. Logs are available and staff are required to track changes on medication specific logs.

Staff will be instructed that ALL orders must be SPECIFIC and not generalized as found during survey. "as ordered" is not appropriate and specific medication orders are required. All orders MUST include name of drug, dose, frequency and route of administration.


How Agency Will Act to Protect Patients in Similar Situations:
100% of SOC/Resumption of Care and Re-certifications shall be reviewed by QA staff upon submission to the agency for the completion of medication reconciliation and detail of orders as listed above and compliance with agency policy for reconciliation.

Measures Taken or Systems Put Into Place to Ensure Problem Does Not Recur :
100% of medication reconciliation shall be reviewed at SOC, ROC and Recertification (until at least 90% overall compliance is achieved) to ensure that appropriate medication reconciliation has been documented and abnormal findings addressed. Conferences with individual staff members (nurses/therapists) related to the need for correction of identified deficiencies shall be documented and available for review. Individual counseling items shall be filed in the personnel record of individual staff member.

Plans To Monitor Performance To Assure Solutions Are Sustained:
Weekly and on-going, the Clinical Manager shall be responsible for enforcing the action necessary to correct this citation. Mandatory staff meetings and/or one-on-one counseling will be conducted by the agency Administrator in response to any issues identified during the QA audits. On-going non-compliance could be considered grounds for termination from the agency.


Date Of When The Corrective Action Will Be Completed:

Corrective action will be completed by 5/9/2019.




484.60(a)(2)(i-xvi) ELEMENT
Plan of care must include the following

Name - Component - 00
The individualized plan of care must include the following:
(i) All pertinent diagnoses;
(ii) The patient's mental, psychosocial, and cognitive status;
(iii) The types of services, supplies, and equipment required;
(iv) The frequency and duration of visits to be made;
(v) Prognosis;
(vi) Rehabilitation potential;
(vii) Functional limitations;
(viii) Activities permitted;
(ix) Nutritional requirements;
(x) All medications and treatments;
(xi) Safety measures to protect against injury;
(xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors.
(xiii) Patient and caregiver education and training to facilitate timely discharge;
(xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient;
(xv) Information related to any advanced directives; and
(xvi) Any additional items the HHA or physician may choose to include.

Observations:


Based upon review of agency policy, job descriptions, medical records (MR), and interview with president (EMP #1), agency failed to ensure the Registered Nurse (RN) completed a review of all medications currently taken during each home visit for seven (7) out of twenty-five (25) MR reviewed. (MR # 7, MR #9, MR # 10, MR# 11, MR #15, MR #22, MR #25) .

Findings included:

Review of agency policy titled " Contents of Plan of Care" on 4/2/19 between approximately 10:00 AM-12:00 PM , stated " The plan, shall include.... " medications and treatments"

Policy titled " Clinical Initial Assessment" stated " Comprehensive review of Medications that the patient is currently taking as well as instructions regarding name, dose, purpose, schedule, adverse reactions, side effects, drug allergies, incompatible medications/foods."

Policy titled " Plan of Care Review" stated " when a significant change in condition... new change orders are added..."

Job description for Staff Nurse/Case Manager stated " (2) Develops and implements a comprehensive goal focused, care plan.." (15) Informs the Supervising Nurse of patient services provided and ended and any changes in the Plan of Care"

Review of MR on 4/2/19 between approximately 12:15 PM-3:00 PM; 4/4/19 between 9:00 AM-11:00 AM and 12:30 PM -1:00 PM; 4/5/19 between 9:15 AM-12:00 PM and 12:30 PM-5:00 PM revealed:

MR # 7, SOC 2/27/19; nighty-two (92) year old male with primary diagnosis of hypertensive heart and chronic kidney disease with heart failure, chronic kidney disease stage 3 chronic combined systolic and diastolic (congestive) heart failure, old heart attach, chronic atrial fibrillation chronic obstructive pulmonary disease atherosclerotic heart disease of native coronary artery
The Certification and Plan of Care, 2/27/19-4/27/19.
Physician's order, " coumadin as ordered".
Does not list the dose, route, frequency, purpose, schedule, adverse reactions, side effects.
Order, " hold coumadin as ordered ".
Does not list the specific order parameters for when to hold and when to administer in addition to not listing dose, route, frequency, purpose, schedule, adverse reactions, side effects.
Order," hold medications as ordered".
Does not list the specific order parameters for when to hold and when to administer in addition to not listing dose, route, frequency, purpose, schedule, adverse reactions, side effects.
Order," medications as ordered".
Does not list the specific order parameters for when to administer in addition to not listing the specific medication, dose, route, frequency, purpose, schedule, adverse reactions, side effects.
Order, " pt/inr checkced as ordered".
Does not list the specific order for PT/ INR testing, how often the PT/ INR is to be taken, what parameters to notify physician.

MR # 9, SOC 10/26/18; seventy-seven (77) year old female with primary diagnosis of general epilepsy rheumatoid arthritis with rheumatoid factor fibromyalgia history of falling, encounter for issue of repeat prescription
The Certification and Plan of Care, 2/23/19-4/23/19, failed to include nursing orders for Subcutaneous (SQ) injection Medication order " Enbrel \ \ solution for injection subcutaneous \ qw \ " this order does not list the dose to be administered.

MR # 10, SOC 3/16/19; sixty-three (63) year old female with primary diagnosis of encounter for adjustment and management of peripherally inserted central catheter (picc) line encounter for issue of repeat prescription abscess of intestine perforation of intestine kidney stone, essential hypertension gastro-esophageal reflux disease
The Certification and Plan of Care, 3/16/19-5/14/19, failed to include complete IV medication order including:
the order " Ertapenem \ 1G/100 ML" \ does not list dose, frequency, route to be administered, purpose, schedule, adverse reactions, side effects.


MR # 11, SOC 12/31/18; eighty-five (85) year old male with primary diagnosis of respiratory failure pneumonia, dependent on supplemental oxygen, vascular dementia epilepsy prosthetic heart valve The Certification and Plan of Care, 3/1/19-4/29/19, failed to include complete medication orders including:
" Iron 325 mg qd no route of administration listed, purpose, schedule, adverse reactions, side effects.
patient on continuous oxygen and oxygen was not documented on medication section of certification and plan of care nor was the dose, route, frequency order present.



MR # 15, SOC 2/4/19; ninety (90) year old female with primary diagnosis of hemiplegia a stroke, aphasia difficulty walking, falling, chronic pain syndrome essential primary hypertension anxiety disorder
The Certification and Plan of Care dated 2/4/19-4/4/19. The patient was admitted to the hospital on 2/18/19 and was not discharged from the hospial until 4/1/19, six (6) weeks later, when a Resumption of Care (ROC) skilled nursing visit was conducted. The agency failed to obtain or show evidence of physician orders including an updated medication list upon discharge from hospital.

MR # 22, SOC 1/20/18; fifty-one (51) year old female with primary diagnosis of encounter for change or removal of surgical wound dressing, non pressure chronic ulcer lower limb, lymphedema pain in right leg, morbid obesity, personal history of other venous thrombosis and embolism osteoarthritis
The Certification and Plan of Care was 10/28/18-12/26/18 with medications listed:
" Citalopram \ 40 mg daily" no route listed.
"Coumadin \ 3 mg tablet every other day" no route listed.
"Diltiazem \ 60 mg twicw daily" no route listed.
"gabapentin \ 100 mg twice daily" no route listed.


. The patient was admitted to the hospital on 11/25/18 and was discharged from the hospital on 11/30/18 ( six (6) days) later with agency failing to obtain or show evidence of physician orders, including an updated medication list, upon resuming care and services.
Patient was readmitted to the hospital on 12/2/18 and discharged from the hospital on 12/8/18 (six (6) days) later with agency failing to obtain or show evidence of physician orders, including an updated medication list, upon resuming care and services.


MR # 25, SOC 3/22/19; eighty-seven (87) year old female with primary diagnosis of encounter for adjustment and management of peripherally inserted central line catheter, encounter for issue of repeat prescription, pneumonia sepsis chronic respiratory failure dependent on supplemental oxygen, type 2 diabetes
The Certification and Plan of Care, 3/22/19-5/20/19, failed to include:
complete IV medication order including:
the order " Ceftriaxone \ 2G/50 ML" \ solution for injection intravenous qd \ does not list dose to be administered, purpose, schedule, adverse reactions, side effects.


Interview with EMP # 1 on 4/8/19 between approximately 11:30 AM-12:30 PM confirmed above findings.
















Plan of Correction:

G 0574 Plan of Care.
Elements Detailing How Deficiency will be Corrected:
An in-service will be conducted by the RN and Administrator on May 9, 2019 regarding all elements of the individualized plan of care. Specific instruction will be provided on the specificity required for medications-dose, route and frequency of administration, and purpose. Dosing parameters are to be set by the physician and documented by the agency clinician. All medications are required to be reconciled at each OASIS D data point and at each change ordered by the physician. Generalized orders such as "per order" is not acceptable. Must list specific medication, dose, route, frequency, purpose, schedule, adverse reactions, side effects. Must list the specific order for PT/INR testing, how often the PT/INR is to be taken, what parameters to notify physician. 100% of all plans of care shall be reviewed for compliance over the next 90 days.
Orders MUST be captured for all patients resuming care following transfer and from an inpatient stay. 100% of all resumed records shall be reviewed for compliance.
Instruction for SCIC assessments will be reviewed during the in-service with specific instruction as to documentation required.
Staff will be instructed that NO home health aide services shall be conducted without a specific plan for care.
Will provide specific direction for the completion of orders for wounds and documentation for all wound care.

How Agency Will Act to Protect Patients in Similar Situations:
QA staff shall review 100% of all plans of care and change orders shall be reviewed for compliance for 90 days. It is expected that there will be a 100% compliance threshold for all corrective action on the Plan of Care and subsequent orders. The clinical manager shall initial and date each plan of care indicating it has been reviewed and that it is in compliance with the plan put into place.


Measures Taken or Systems Put Into Place to Ensure Problem Does Not Recur:
100% of all plans of care and change orders shall be reviewed at SOC, ROC and Recertification and at any time an update is made (until at least 90% overall compliance is achieved) to ensure that complete and accurate orders have been documented. Conferences with individual staff members (nurses/therapists) related to the need for correction of identified deficiencies shall be documented and available for review. Individual counseling items shall be filed in the personnel record of individual staff member.

Plans To Monitor Performance To Assure Solutions Are Sustained:
A 100% compliance threshold is required. 100% review of all plans of care/change orders shall take place until threshold is met. Weekly and on-going, the Clinical Manager shall be responsible for enforcing the action necessary to correct this citation. Mandatory staff meetings and/or one-on-one counseling will be conducted by the agency Administrator in response to any issues identified during the QA audits. On-going non-compliance could be considered grounds for termination from the agency.

Date Of When The Corrective Action Will Be Completed:

Corrective action will be completed by 5/9/2019.




484.60(a)(3) ELEMENT
All orders recorded in plan of care

Name - Component - 00
All patient care orders, including verbal orders, must be recorded in the plan of care.

Observations:


Based upon review of agency policy, medical records (MR), and interview with president (EMP #1), agency failed to include all patient care orders, including verbal orders, in the plan of care for nineteen (19) out of twenty-five (25) MR reviewed. ( MR # 1, MR # 2, MR # 5, MR # 8-17, MR # 19-22, MR # 24, MR # 25).

Findings included:

Review of agency policy titled " Contents of Plan of Care" on 4/2/19 between approximately 10:00 AM-12:00 PM , stated " The plan, shall include.... " Types, amount, and duration of services; frequency of visits; equipment required; goals, prognosis, and rehabilitation potential; functional limitations/activities permitted; nutritional requirements; medications and treatments; safety measures to protect against injury; other appropriate items; and orders for therapy services to be provided include the following: specific procedures to be used; specific modalities to be used; amount; frequency; and duration".

Policy titled " Clinical Initial Assessment" stated " Comprehensive review of Medications that the patient is currently taking as well as instructions regarding name, dose, purpose, schedule, adverse reactions, side effects, drug allergies, incompatible medications/foods."

Policy titled " Plan of Care Review" stated " when a significant change in condition... new change orders are added..."


Review of MR on 4/2/19 between approximately 12:15 PM-3:00 PM; 4/4/19 between 9:00 AM-11:00 AM and 12:30 PM -1:00 PM; 4/5/19 between 9:15 AM-12:00 PM and 12:30 PM-5:00 PM revealed:

MR # 1, Start of Care (SOC) 3/15/19; ninety (90) year old male with primary diagnosis of pressure ulcer of left heel, pressure ulcer of sacral area, muscle weakness, and Diabetes The physician orders, 3/15/19-5/13/19, failed to include wound care orders for left heel and also sacral area; no aide care plan established.

MR # 2, SOC 12/28/18; ninety-three (93) year old female with primary diagnosis of encounter for change or removal of nonsurgical wound dressing, non pressure ulcer of right heel, non pressure chronic ulcer of right ankle, peripheral vascular disease (circulatory vascular disease with narrowed arteries and decreased blood flow), muscle weakness. The physician orders, 12/27/18 specify " Please provide daily dressing changes x 1 wk until follow up with \ 1/3/19. 1. Clean wounds with wound cleanser, 2. Maxorb extra ag to R dorsal foot wound and medial ankle wound and L medial foot wound, 3. cover sponge, 4. gauze roll, 5. single Tubigrip layer D"
New Physician orders, 12/28/18-2/25/19, failed to carry over wound care treatment orders from 12/27/18 with no specific treatment orders documented.
Updated physician orders, 1/17/19, specify " Please continue c \ daily dsg \ changes to L foot, Santyl to wound bed ..cover sponge, abd, gauze roll. Will discontinue Mepilex donut for offloading a \ this time since pt not wearing a shoe. R medial foot Mepilex border lite. Single layer Tubigrip D to both lower legs."
Physician orders, 2/21/19, specified " continue every other day dressing changes to all wounds."
New physician orders, 2/25/19-4/25/19, failed to carry over wound care treatment orders from 1/17/19 or 2/21/19 with no specific treatment orders documented.
patient was hospitalized and no resumption of care orders were obtained for skilled nursing including wound care orders or physical therapy orders.


MR # 5, SOC 3/4/19; sixty-six (66) year old female with primary diagnosis of cutaneous abscess of right foot unspecified open wound in right foot, cellulitis of right lower limb change or removal non surgical wound dressing, atherosclerotic heart disease of native coronary artery
Physician orders, given at time of referral on 3/1/19, stated " Dressing- Iodoform packing 1/4 inch R \ foot daily S/P \ I.D.\ 2/28/19"
Upon admission, physician orders 3/4/19-5/2/19, failed to carry over wound care treatment orders from 3/1/19 with no specific treatment orders documented.


MR # 8, SOC 3/15/19; eight -four (84) year old male with primary diagnosis of malignant neoplasm of unspecified main bronchus secondary neoplasm of bone and bone marrow, neoplasm of liver and bile duct, unspecified atrial fibrillation pacemaker, difficulty walking. The physician orders , 3/15/19-5/13/19, failed to include order for medical social worker ( MSW).


MR # 9, SOC 10/26/18; seventy-seven (77) year old female with primary diagnosis of general epilepsy rheumatoid arthritis with rheumatoid factor fibromyalgia history of falling, encounter for issue of repeat prescription The physician orders, 2/23/19-4/23/19, failed to include nursing orders for administering Subcutaneous (SQ) injection order for PT/ INR \ or order for Occupational Therapist.

MR # 10, SOC 3/16/19; sixty-three (63) year old female with primary diagnosis of encounter for adjustment and management of peripherally inserted central catheter (picc) line encounter for issue of repeat prescription abscess of intestine perforation of intestine kidney stone, essential hypertension gastro-esophageal reflux disease Physician orders, 3/16/19-5/14/19, failed to include complete IV medication order "Ertapenem \ 1 G/100 ML missing route, frequency, no orders for PICC \ line care, measurement of arm circumference, measuring length of catheter to assess migration, no order for lab draws including type of tube, frequency, when to report to physician.

MR # 11, SOC 12/31/18; eighty-five (85) year old male with primary diagnosis of respiratory failure pneumonia, dependent on supplemental oxygen, vascular dementia epilepsy prosthetic heart valve The physician orders, 3/1/19-4/29/19, failed to include lab draws including type of tube, frequency, when to report to physician; physical therapy order only states " continue plan of care" but failed to include specific orders.


MR # 12, SOC 4/1/19; seventy-four (74) year old female with primary diagnosis of encounter of surgical aftercare following surgery on digestive system, acquired absence of other specified parts of digestive tract, malignant neoplasm \ of colon, secondary malignant neoplasm of liver and bile duct. The physician orders, 4/1/19-5/30/19, failed to include wound vac care orders for prepping skin or weekly cannister changes.

MR # 13, SOC 7/16/18; ninety-five (95) year old female with primary diagnosis of unspecified open wound of other body part, history of falling, muscle weakness, dementia, and essential primary hypertension The physician orders, 3/13/19-5/11/19, failed to include wound care orders for head wound.

MR # 14, SOC 3/3/19; sixty-two (62) year old female with primary diagnosis of non-pressure chronic ulcer of unspecified part of right lower leg, cellulitis encounter for change or removal of nonsurgical wound dressing, sepsis enterocolitis essential primary hypertension atrial fibrillation The physician orders, 3/3/19-5/1/19, failed to include wound care orders.

MR # 15, SOC 2/4/19; ninety (90) year old female with primary diagnosis of hemiplegia a stroke, aphasia difficulty walking, falling, chronic pain syndrome essential primary hypertension anxiety disorder The physician orders, 2/4/19-4/4/19. Patient was hospitalized 2/18/19-3/31/19, and agency failed to obtain orders to resume care on 4/1/19 including skilled nursing and physical therapy services.


MR # 16, SOC 3/7/19; seventy-two (72) year old male with primary diagnosis of fracture of sacrum kissing spine low back pain, rheumatoid arthritis weakness, lymphedema prostatic hyperplasia The Certification and Plan of Care, 3/7/19-5/5/19, failed to include physical therapy orders for treatment and goals.

MR # 17, SOC 2/13/19; seventy-one (71) year old male with primary diagnosis of fracture of humerus history of falling, atherosclerotic heart disease of native coronary artery essential primary hypertension atrial fibrillation nicotine dependence. The physician orders, 2/13/19-4/13/19, failed to include orders for Physical Therapy and Home Health Aide services.


MR # 19, SOC 11/9/18; eighty-four (84) year old male with primary diagnosis of aftercare following joint replacement, fracture of femur artificial left hip, pain in left hip, history of falling, dementia chronic obstructive pulmonary disease The physician orders, 11/9/18-1/7/19, failed to include physical therapy discharge orders for 12/26/19. Final agency discharge was on 12/29/18 by nursing.

MR # 20, SOC 6/8/18; ninety (90) year old female with primary diagnosis of osteoarthritis pain in left knee, wheelchair dependent, chronic kidney disease, chronic obstructive pulmonary disease peripheral vascular disease the physician orders, 8/7/18-10/5/18, failed to include orders for Physical Therapy services.

MR # 21, SOC 12/23/18; fifty-seven (57) year old male with primary diagnosis of encounter for change or removal of surgical wound dressing, open wound of lower back and pelvis, pressure ulcer \ of other site stage 4, burn of left lower leg, osteomyelitis paraplegia long term use of antibiotics. The physician orders, 12/23/18-2/20/19 stated " SN to instruct PT/CG \ in wound care/suture line care: WTD \ daily to left lateral leg" order failed to include what solution to use, sterile or aseptic technique, what supplies were needed such as gloves and wound care supplies or how often to complete wound measurements. No order for when to contact the physician.
Physician orders, 2/21/19-4/21/19, stated " SN to instruct PT/CG \ in wound care/suture line care: " WTD \ change daily to left lateral leg" order failed to include what solution to use, sterile or aseptic technique, what supplies were needed such as gloves and wound care supplies or how often to complete wound measurements. No order for when to contact the physician.


MR # 22, SOC 1/20/18; fifty-one (51) year old female with primary diagnosis of encounter for change or removal of surgical wound dressing, non pressure chronic ulcer lower limb, lymphedema pain in right leg, morbid obesity, personal history of other venous thrombosis and embolism osteoarthritis The physician orders, 10/28/18-12/26/18, state " PT/INR checks as directed" no specific order present. Skilled nursing frequency: 1-2 x week x 60 days; 10 prn visits for wound care" and 60 day summary: " receiving SN \ services for wound care to non-healing chronic venous stasis ulcer"
physician orders were not obtained for skilled nursing to resume care and services on 11/30/18 including wound care and/or PT INR bloodwork.
Physician orders were not obtained for skilled nursing or physical therapy services to resume care on 12/8/18 including wound care and/ or PT INR bloodwork.

MR # 24, SOC 2/19/19; eighty-three (83) year old female with primary diagnosis of atrial fibrillation long term use of anticoagulants, muscle weakness, hypertensive chronic kidney disease type 2 diabetesdifficulty walking. The physician orders, 2/19/19-4/19/19, failed to include physical therapy services with frequency.

MR # 25, SOC 3/22/19; eighty-seven (87) year old female with primary diagnosis of encounter for adjustment and management of peripherally inserted central line catheter, encounter for issue of repeat prescription, pneumonia sepsis chronic respiratory failure dependent on supplemental oxygen, type 2 diabetes The physician orders, 3/22/19-5/20/19, state " perform PICC care" no mention of frequency of dressing change; parameters to contact physician; arm measurement or length of PICC tubing. In addition, no orders for blood work.


Interview with EMP # 1 on 4/8/19 between approximately 11:30 AM-12:30 PM confirmed above findings.















Plan of Correction:

G 0576 All Orders Recorded In Plan Of Care.

Elements Detailing How Deficiency will be Corrected:
An in-service will be held on May 9, 2019 conducted by the Agency Administrator and Clinical Manager re: Conformance with physician orders. The professional staff will be issued copies of guidelines relative to this Standard as well as copy of agency policy outlining requirements for securing orders from the physician and job descriptions outlining responsibilities for all physician orders, treatments and medications.
Additional items instructed upon will be the absolute requirement for the specific wound care ordered by the physician, assuring aide care plans are complete prior to the assignment of the aide. In-services shall be held monthly to review progress for at least one quarter.

How Agency Will Act to Protect Patients in Similar Situations:
The QA staff under the direction of the Clinical manager, shall be responsible for an entire record review for each new admission, resumption of care and recertification in the agency. 100% of all records shall be reviewed for compliance in all areas required by CoPs and Agency Policy. A report by the QA staff will be submitted to the Clinical Manager at least weekly. A summary of findings shall be submitted to the Administrator on a monthly basis for at least one full quarter.

Measures Taken or Systems Put Into Place to Ensure Problem Does Not Recur:
100% of all plans of care and change orders shall be reviewed at SOC, ROC and Recertification and at any time an update is made (until at least 90% overall compliance is achieved) to ensure that complete and accurate orders have been documented. Conferences with individual staff members (nurses/therapists) related to the need for correction of identified deficiencies shall be documented and available for review. Individual counseling items shall be filed in the personnel record of individual staff member.


Plans To Monitor Performance To Assure Solutions Are Sustained:
A 100% compliance threshold is required.100% review of all plans of care/change orders shall take place until threshold is met. Weekly and on-going, the Clinical Manager shall be responsible for enforcing the action necessary to correct this citation. Mandatory staff meetings and/or one-on-one counseling will be conducted by the agency Administrator in response to any issues identified during the QA audits. On-going non-compliance could be considered grounds for termination from the agency.

Date Of When The Corrective Action Will Be Completed:

Corrective action will be completed by 5/9/2019.




484.75(b) STANDARD
Responsibilities of skilled professionals

Name - Component - 00
Standard: Responsibilities of skilled professionals.
Skilled professionals must assume responsibility for, but not be restricted to, the following:

Observations:


Based upon review of agency policy, job descriptions, medical records (MR), skilled visit notes, and interview with president (EMP #1), skilled nursing failed to ensure the agency staff followed the plan of care or obtained updated physician orders for nineteen (19) of twenty-five (25) records reviewed. (MR # 1, MR #2 MR #5, MR #8, MR # 9, MR # 10, MR #11-17, MR # 19, MR # 20, MR # 21, MR #22, MR #24, MR # 25).

Findings included:

Review of agency policy titled " Contents of Plan of Care" on 4/2/19 between approximately 10:00 AM-12:00 PM , stated " The plan, shall include.... " Types, amount, and duration of services; frequency of visits; equipment required; goals, prognosis, and rehabilitation potential; functional limitations/activities permitted; nutritional requirements; medications and treatments; safety measures to protect against injury; other appropriate items; and orders for therapy services to be provided include the following: specific procedures to be used; specific modalities to be used; amount; frequency; and duration".

Policy titled " Clinical Initial Assessment" stated " Comprehensive review of Medications that the patient is currently taking as well as instructions regarding name, dose, purpose, schedule, adverse reactions, side effects, drug allergies, incompatible medications/foods."

Policy titled " Start of Care Documents" stated " The following is the documentation requirements for the Start of Care Assessment: Patient problem list; Patient goal list; name of physician contacted for the confirmation of the Plan of Care"; Interventions performed..."

Policy titled " Plan of Care Review" stated " when a significant change in condition... new change orders are added..."

Job description for Staff Nurse/Case Manager stated " (2) Develops and implements a comprehensive goal focused, care plan.." (15) Informs the Supervising Nurse of patient services provided and ended and any changes in the Plan of Care"


Review of MR on 4/2/19 between approximately 12:15 PM-3:00 PM; 4/4/19 between 9:00 AM-11:00 AM and 12:30 PM -1:00 PM; 4/5/19 between 9:15 AM-12:00 PM and 12:30 PM-5:00 PM revealed:

MR # 1, Start of Care (SOC) 3/15/19; ninety (90) year old male with primary diagnosis of pressure ulcer of left heel, pressure ulcer of sacral area, muscle weakness, and Diabetes The physician orders, 3/15/19-5/13/19, failed to include wound care orders for left heel and also sacral area; no aide care plan established.

MR # 2, SOC 12/28/18; ninety-three (93) year old female with primary diagnosis of encounter for change or removal of nonsurgical wound dressing, non pressure ulcer of right heel, non pressure chronic ulcer of right ankle, peripheral vascular disease (circulatory vascular disease with narrowed arteries and decreased blood flow), muscle weakness. The physician orders, 12/27/18 specify " Please provide daily dressing changes x 1 wk until follow up with \ 1/3/19. 1. Clean wounds with wound cleanser, 2. Maxorb extra ag to R dorsal foot wound and medial ankle wound and L medial foot wound, 3. cover sponge, 4. gauze roll, 5. single Tubigrip layer D"
New Physician orders, 12/28/18-2/25/19, failed to carry over wound care treatment orders from 12/27/18 with no specific treatment orders documented.
Updated physician orders, 1/17/19, specify " Please continue c \ daily dsg \ changes to L foot, Santyl to wound bed ..cover sponge, abd, gauze roll. Will discontinue Mepilex donut for offloading a \ this time since pt not wearing a shoe. R medial foot Mepilex border lite. Single layer Tubigrip D to both lower legs."
Physician orders, 2/21/19, specified " continue every other day dressing changes to all wounds."
New physician orders, 2/25/19-4/25/19, failed to carry over wound care treatment orders from 1/17/19 or 2/21/19 with no specific treatment orders documented.
patient was hospitalized and no resumption of care orders were obtained for skilled nursing including wound care orders or physical therapy orders.


MR # 5, SOC 3/4/19; sixty-six (66) year old female with primary diagnosis of cutaneous abscess of right foot unspecified open wound in right foot, cellulitis of right lower limb change or removal non surgical wound dressing, atherosclerotic heart disease of native coronary artery
Physician orders, given at time of referral on 3/1/19, stated " Dressing- Iodoform packing 1/4 inch R \ foot daily S/P \ I.D.\ 2/28/19"
Upon admission, physician orders 3/4/19-5/2/19, failed to carry over wound care treatment orders from 3/1/19 with no specific treatment orders documented.


MR # 8, SOC 3/15/19; eight -four (84) year old male with primary diagnosis of malignant neoplasm of unspecified main bronchus secondary neoplasm of bone and bone marrow, neoplasm of liver and bile duct, unspecified atrial fibrillation pacemaker, difficulty walking. The physician orders , 3/15/19-5/13/19, failed to include order for medical social worker ( MSW).


MR # 9, SOC 10/26/18; seventy-seven (77) year old female with primary diagnosis of general epilepsy rheumatoid arthritis with rheumatoid factor fibromyalgia history of falling, encounter for issue of repeat prescription The physician orders, 2/23/19-4/23/19, failed to include nursing orders for administering Subcutaneous (SQ) injection order for PT/ INR \ or order for Occupational Therapist.

MR # 10, SOC 3/16/19; sixty-three (63) year old female with primary diagnosis of encounter for adjustment and management of peripherally inserted central catheter (picc) line encounter for issue of repeat prescription abscess of intestine perforation of intestine kidney stone, essential hypertension gastro-esophageal reflux disease Physician orders, 3/16/19-5/14/19, failed to include complete IV medication order "Ertapenem \ 1 G/100 ML missing route, frequency, no orders for PICC \ line care, measurement of arm circumference, measuring length of catheter to assess migration, no order for lab draws including type of tube, frequency, when to report to physician.

MR # 11, SOC 12/31/18; eighty-five (85) year old male with primary diagnosis of respiratory failure pneumonia, dependent on supplemental oxygen, vascular dementia epilepsy prosthetic heart valve The physician orders, 3/1/19-4/29/19, failed to include lab draws including type of tube, frequency, when to report to physician; physical therapy order only states " continue plan of care" but failed to include specific orders.


MR # 12, SOC 4/1/19; seventy-four (74) year old female with primary diagnosis of encounter of surgical aftercare following surgery on digestive system, acquired absence of other specified parts of digestive tract, malignant neoplasm \ of colon, secondary malignant neoplasm of liver and bile duct. The physician orders, 4/1/19-5/30/19, failed to include wound vac care orders for prepping skin or weekly cannister changes.

MR # 13, SOC 7/16/18; ninety-five (95) year old female with primary diagnosis of unspecified open wound of other body part, history of falling, muscle weakness, dementia, and essential primary hypertension The physician orders, 3/13/19-5/11/19, failed to include wound care orders for head wound.

MR # 14, SOC 3/3/19; sixty-two (62) year old female with primary diagnosis of non-pressure chronic ulcer of unspecified part of right lower leg, cellulitis encounter for change or removal of nonsurgical wound dressing, sepsis enterocolitis essential primary hypertension atrial fibrillation The physician orders, 3/3/19-5/1/19, failed to include wound care orders.

MR # 15, SOC 2/4/19; ninety (90) year old female with primary diagnosis of hemiplegia a stroke, aphasia difficulty walking, falling, chronic pain syndrome essential primary hypertension anxiety disorder The physician orders, 2/4/19-4/4/19. Patient was hospitalized 2/18/19-3/31/19, and agency failed to obtain orders to resume care on 4/1/19 including skilled nursing and physical therapy services.


MR # 16, SOC 3/7/19; seventy-two (72) year old male with primary diagnosis of fracture of sacrum kissing spine low back pain, rheumatoid arthritis weakness, lymphedema prostatic hyperplasia The Certification and Plan of Care, 3/7/19-5/5/19, failed to include physical therapy orders for treatment and goals.

MR # 17, SOC 2/13/19; seventy-one (71) year old male with primary diagnosis of fracture of humerus history of falling, atherosclerotic heart disease of native coronary artery essential primary hypertension atrial fibrillation nicotine dependence. The physician orders, 2/13/19-4/13/19, failed to include orders for Physical Therapy and Home Health Aide services.


MR # 19, SOC 11/9/18; eighty-four (84) year old male with primary diagnosis of aftercare following joint replacement, fracture of femur artificial left hip, pain in left hip, history of falling, dementia chronic obstructive pulmonary disease The physician orders, 11/9/18-1/7/19, failed to include physical therapy discharge orders for 12/26/19. Final agency discharge was on 12/29/18 by nursing.

MR # 20, SOC 6/8/18; ninety (90) year old female with primary diagnosis of osteoarthritis pain in left knee, wheelchair dependent, chronic kidney disease, chronic obstructive pulmonary disease peripheral vascular disease the physician orders, 8/7/18-10/5/18, failed to include orders for Physical Therapy services.

MR # 21, SOC 12/23/18; fifty-seven (57) year old male with primary diagnosis of encounter for change or removal of surgical wound dressing, open wound of lower back and pelvis, pressure ulcer \ of other site stage 4, burn of left lower leg, osteomyelitis paraplegia long term use of antibiotics. The physician orders, 12/23/18-2/20/19 stated " SN to instruct PT/CG \ in wound care/suture line care: WTD \ daily to left lateral leg" order failed to include what solution to use, sterile or aseptic technique, what supplies were needed such as gloves and wound care supplies or how often to complete wound measurements. No order for when to contact the physician.
Physician orders, 2/21/19-4/21/19, stated " SN to instruct PT/CG \ in wound care/suture line care: " WTD \ change daily to left lateral leg" order failed to include what solution to use, sterile or aseptic technique, what supplies were needed such as gloves and wound care supplies or how often to complete wound measurements. No order for when to contact the physician.


MR # 22, SOC 1/20/18; fifty-one (51) year old female with primary diagnosis of encounter for change or removal of surgical wound dressing, non pressure chronic ulcer lower limb, lymphedema pain in right leg, morbid obesity, personal history of other venous thrombosis and embolism osteoarthritis The physician orders, 10/28/18-12/26/18, state " PT/INR checks as directed" no specific order present. Skilled nursing frequency: 1-2 x week x 60 days; 10 prn visits for wound care" and 60 day summary: " receiving SN \ services for wound care to non-healing chronic venous stasis ulcer"
physician orders were not obtained for skilled nursing to resume care and services on 11/30/18 including wound care and/or PT INR bloodwork.
Physician orders were not obtained for skilled nursing or physical therapy services to resume care on 12/8/18 including wound care and/ or PT INR bloodwork.

MR # 24, SOC 2/19/19; eighty-three (83) year old female with primary diagnosis of atrial fibrillation long term use of anticoagulants, muscle weakness, hypertensive chronic kidney disease type 2 diabetesdifficulty walking. The physician orders, 2/19/19-4/19/19, failed to include physical therapy services with frequency.

MR # 25, SOC 3/22/19; eighty-seven (87) year old female with primary diagnosis of encounter for adjustment and management of peripherally inserted central line catheter, encounter for issue of repeat prescription, pneumonia sepsis chronic respiratory failure dependent on supplemental oxygen, type 2 diabetes The physician orders, 3/22/19-5/20/19, state " perform PICC care" no mention of frequency of dressing change; parameters to contact physician; arm measurement or length of PICC tubing. In addition, no orders for blood work.


Interview with EMP # 1 on 4/8/19 between approximately 11:30 AM-12:30 PM confirmed above findings.














Plan of Correction:

G 0704 Responsibilities Of Skilled Professionals.

Elements Detailing How Deficiency will be Corrected:
An in-service will be held on May 9, 2019 conducted by the Agency Administrator and Clinical Manager re: Conformance with physician orders. The professional staff will be issued copies of guidelines relative to this Standard as well as copy of agency policy outlining requirements for securing orders from the physician and job descriptions outlining responsibilities for all physician orders, treatments and medications.
Additional items instructed upon will be the absolute requirement for the specific wound care ordered by the physician, assuring aide care plans are complete prior to the assignment of the aide. In-services shall be held monthly to review progress for at least one quarter.

How Agency Will Act to Protect Patients in Similar Situations:
The QA staff under the direction of the Clinical manager, shall be responsible for an entire record review for each new admission, resumption of care and recertification in the agency. 100% of all records shall be reviewed for compliance in all areas required by CoPs and Agency Policy. A report by the QA staff will be submitted to the Clinical Manager at least weekly. A summary of findings shall be submitted to the Administrator on a monthly basis for at least one full quarter.

Measures Taken or Systems Put Into Place to Ensure Problem Does Not Recur:
100% of all plans of care and change orders shall be reviewed at SOC, ROC and Recertification and at any time an update is made (until at least 90% overall compliance is achieved) to ensure that complete and accurate orders have been documented. Conferences with individual staff members (nurses/therapists) related to the need for correction of identified deficiencies shall be documented and available for review. Individual counseling items shall be filed in the personnel record of individual staff member.


Plans To Monitor Performance To Assure Solutions Are Sustained:
A 100% compliance threshold is required.100% review of all plans of care/change orders shall take place until threshold is met. Weekly and on-going, the Clinical Manager shall be responsible for enforcing the action necessary to correct this citation. Mandatory staff meetings and/or one-on-one counseling will be conducted by the agency Administrator in response to any issues identified during the QA audits. On-going non-compliance could be considered grounds for termination from the agency.

Date Of When The Corrective Action Will Be Completed:

Corrective action will be completed by 5/9/2019.




484.100 CONDITION
Compliance with Federal, State, Local Law

Name - Component - 00
Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients.

The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed.

Observations:


Based upon review of CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, 2005, agency policy, personnel files (PF), and interview with president (EMP #1), agency failed to obtain timely initial Tuberculin (TB) screening for three (3) out of five (5) PF reviewed ( PF # 1; PF # 2; PF # 5) and timely annual screenings for two (2) out of five (5) PF reviewed. ( PF # 3; PF # 6).

Findings included:

Review of CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in health-Care Settings, 2005, included that all Health Care Workers (HCW) should receive baseline TB screening upon hire, using two-step TST or a single BAMT to test for infection with M. Tuberculosis. The second step TST should be administered 1-3 weeks after the first step was read.

Review of agency policy titled " Health Requirements" on 4/9/19 between approximately 10:00 AM-12:00 PM , stated " All employees... shall provide proof of testing... Documentation related to TB may include.. results of 2 step T.B. skin testing within the previous 12 months. On an annual basis, the employee will complete documentation indicating that he/she is free from signs/symptoms of TB".

Review of PF on 4/8/19 between approximately 8:30 AM-11:30 AM revealed:

PF # 1, Date of Hire (DOH) 5/9/16; initial TB screening administered 5/5/16 and read on 5/7/16. No evidence second step TB was completed. No evidence of annual TB given for 2018.

PF # 2, DOH 1/11/17; initial TB screening administered 1/9/17 and read on 1/11/17. No evidence second step TB was completed.

PF # 3, DOH 5/9/16; second step TB administered on 1/20/16 and read on 1/22/16. Annual TB was administered 5/17/17 and read on 5/19/17 (4 months past anniversary of prior TB) and annual TB for 2018 administered on 9/24/18 and read on 9/27/18 ( 4 months past anniversary of prior TB).

PF # 5, DOH 11/30/16; Initial TB screening administered 7/6/16 and read on 7/8/16 with second step administered 4/19/17 and read on 4/21/17 ( five (5) months after hire).

PF # 6, DOH 10/3/16; second step TB administered on 8/28/16 and read on 8/30/16. Annual TB was administered 9/24/17 and read on 9/27/17 (1 month past anniversary of prior TB).

Interview with EMP # 1 on 4/9/19 between approximately 11:30 AM-12:30 PM confirmed above findings.












Plan of Correction:

G 0848 Compliance with Federal, State, Local Law.

Elements Detailing How Deficiency will be Corrected:
The board of directors had a meeting on 4/29/2019 and revised the policy on TB testing to meet the specifications in the CDC guidelines. All employee files will be reviewed and all the field staff will be brought into compliance no later than May 9, 2019. All field staff will be tested annually before their anniversary date. All new employees will be tested upon hire according to CDC guidelines.
How Agency Will Act to Protect Patients in Similar Situations:
All employee files will be reviewed and all the field staff will be brought into compliance no later than May 9, 2019. All field staff will be tested annually before their anniversary date.
Measures Taken or Systems Put Into Place to Ensure Problem Does Not Recur:
The office manager will be responsible for monitoring compliance and keeping personnel files up to date and in compliance with revised TB policy. A tracking of all TB testing will be filed in each personnel file and results will be filed in the medical portion of the personnel file.
Plans To Monitor Performance To Assure Solutions Are Sustained:
All TB testing in compliance with agency policy will be tracked results filed in the individual employees health file. The results of the plan will be monitored by the Agency Administrator for 1 full year. The Agency Administrator will be responsible for enforcing compliance with the corrective plan. Should the issue not be resolved, mandatory staff meetings and/or individual counseling will be conducted by the Agency Administrator for any staff members who violate this Standard.

Date Of When The Corrective Action Will Be Completed:

Corrective action will be completed by 5/9/2019.



Initial Comments:

Based on the findings of an unannounced on-site home health Medicare re-certification and state re-licensure survey conducted between 4/2/19 through 4/8/19, Community Home Health Care, Inc. was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies-Emergency Preparedness.





Plan of Correction:




Initial Comments:

Based on the findings of an unannounced on-site home health Medicare re-certification and state re-licensure survey conducted between 4/2/19 through 4/9/19, Community Home Health Care, Inc. was found to be not in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.







Plan of Correction:




601.21(f) REQUIREMENT
PERSONNEL POLICIES

Name - Component - 00
601.21(f) Personnel Policies.
Personnel practices and patient care
are supported by appropriate, written
personnel policies. Personnel records
include qualifications, licensure,
performance evaluations, health
examinations, documentation of
orientation provided, and job
descriptions, and are kept current.

Observations:



Based upon review of CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, 2005, agency policy, personnel files (PF), and interview with president (EMP #1), agency failed to obtain timely initial Tuberculin (TB) screening for three (3) out of five (5) PF reviewed ( PF # 1; PF # 2; PF # 5) and timely annual screenings for two (2) out of five (5) PF reviewed. ( PF # 3; PF # 6).

Findings included:

Review of CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in health-Care Settings, 2005, included that all Health Care Workers (HCW) should receive baseline TB screening upon hire, using two-step TST or a single BAMT to test for infection with M. Tuberculosis. The second step TST should be administered 1-3 weeks after the first step was read. Include verbage regarding recommendation for annual screenings to include timeframes from one year to next.

Review of agency policy titled " Health Requirements" on 4/9/19 between approximately 10:00 AM-12:00 PM , stated " All employees... shall provide proof of testing... Documentation related to TB may include.. results of 2 step T.B. skin testing within the prvious 12 months. On an annual basis, the employee will complete documentation indicating that he/she is free from signs/symptoms of TB".

Review of PF on 4/8/19 between approximately 8:30 AM-11:30 AM revealed:

PF # 1, Date of Hire (DOH) 5/9/16; initial TB screening administered 5/5/16 and read on 5/7/16. No evidence second step TB was completed. No evidence of annual TB given for 2018.

PF # 2, DOH 1/11/17; initial TB screening administered 1/9/17 and read on 1/11/17. No evidence second step TB was completed.

PF # 3, DOH 5/9/16; second step TB administered on 1/20/16 and read on 1/22/16. Annual TB was administered 5/17/17 and read on 5/19/17 (4 months past anniversary of prior TB) and annual TB for 2018 administered on 9/24/18 and read on 9/27/18 ( 4 months past anniversary of prior TB).

PF # 5, DOH 11/30/16; Initial TB screening administered 7/6/16 and read on 7/8/16 with second step administered 4/19/17 and read on 4/21/17 ( five (5) months after hire).

PF # 6, DOH 10/3/16; second step TB administered on 8/28/16 and read on 8/30/16. Annual TB was administered 9/24/17 and read on 9/27/17 (1 month past anniversary of prior TB).

Interview with EMP # 1 on 4/9/19 between approximately 11:30 AM-12:30 PM confirmed above findings.









Plan of Correction:

M 1007 Personal Policies.

Elements Detailing How Deficiency will be Corrected:
The board of directors had a meeting on 4/29/2019 and revised the policy on TB testing to meet the specifications in the CDC guidelines. All employee files will be reviewed and all the field staff will be brought into compliance no later than May 9, 2019. All field staff will be tested annually before their anniversary date. All new employees will be tested upon hire according to CDC guidelines.
How Agency Will Act to Protect Patients in Similar Situations:
All employee files will be reviewed and all the field staff will be brought into compliance no later than May 9, 2019. All field staff will be tested annually before their anniversary date.
Measures Taken or Systems Put Into Place to Ensure Problem Does Not Recur:
The office manager will be responsible for monitoring compliance and keeping personnel files up to date and in compliance with revised TB policy.A tracking of all TB testing will be filed in each personnel file and results will be filed in the medical portion of the personnel file.
Plans To Monitor Performance To Assure Solutions Are Sustained:
All TB testing in compliance with agency policy will be tracked results filed in the individual employees health file. The results of the plan will be monitored by the Agency Administrator for 1 full year. The Agency Administrator will be responsible for enforcing compliance with the corrective plan. Should the issue not be resolved, mandatory staff meetings and/or individual counseling will be conducted by the Agency Administrator for any staff members who violate this Standard.

Date Of When The Corrective Action Will Be Completed:

Corrective action will be completed by 5/9/2019.




601.21(h) REQUIREMENT
COORDINATION OF PATIENT SERVICES

Name - Component - 00
601.21(h) Coordination of Patient
Services. All personnel providing
services maintain liason to assure
that their efforts effectively
complement one another and support the
objectives outlined in the plan of
treatment. (i) The clinical record
or minutes of case conferences
establish that effective interchange,
reporting, and coordinated patient
evaluation does occur. (ii) A
written summary report for each
patient is sent to the attending
physician at least every 60 days.

Observations:


Based upon review of agency policy, medical records (MR), and interview with president (EMP #1), agency failed to send 60 day summary reports to the physician for eight (8) out of twenty-five (25) files reviewed. ( MR # 2; MR #4; MR #6; MR #9; MR # 11; MR # 13; MR 20; MR # 21; ).


Findings included:

Review of agency policy on 4/2/19 between approximately 10:00 AM-12:00 PM, titled " 60- Day Summary to the Physician" stated " A written summary report is sent to the attending physician for each patient at least every 60 days."

Review of MR on 4/2/19 between approximately 12:15 PM-3:00 PM; 4/4/19 between 9:00 AM-11:00 AM and 12:30 PM -1:00 PM; 4/5/19 between 9:15 AM-12:00 PM and 12:30 PM-5:00 PM revealed:

MR # 2, SOC 12/28/18; ninety-three (93) year old female with primary diagnosis of encounter for change or removal of nonsurgical wound dressing, non pressure ulcer of right heel, non pressure chronic ulcer of right ankle, peripheral vascular disease (circulatory vascular disease with narrowed arteries and decreased blood flow), muscle weakness. The Certification and Plan of Care, 2/25/19-4/25/19, failed to include a 60 day summary for the physician.

MR # 4, SOC 12/30/18; eighty-four (84) year old female with primary diagnosis of type two (2) diabetes mellitus with diabetic neuropathy history of urinary tract infections, fitting for and adjustment of urinary device, spinal stenosis peripheral vascular disease atrial fibrillation The Certification and Plan of Care, 2/28/19-4/28/19, failed to include a 60 day summary for the physician.

MR # 6, SOC 1/16/19; eighty-seven (87) year old male with primary diagnosis of generalized muscle weakness, pneumonia, hypertensive chronic kidney disease kidney disease due to type two (2) diabetes dementia atherosclerotic heart disease of native coronary artery The Certification and Plan of Care, 3/17/19-5/15/19, failed to include a 60 day summary for the physician.

MR # 9, SOC 10/26/18; seventy-seven (77) year old female with primary diagnosis of general epilepsy rheumatoid arthritis with rheumatoid factor fibromyalgia history of falling, encounter for issue of repeat prescription The Certification and Plan of Care, 2/23/19-4/23/19, failed to include
a 60 day summary for the physician.

MR # 11, SOC 12/31/18; eighty-five (85) year old male with primary diagnosis of respiratory failure pneumonia, dependent on supplemental oxygen, vascular dementia epilepsy prosthetic heart valve The Certification and Plan of Care, 3/1/19-4/29/19, failed to include a 60 day summary for the physician.

MR # 13, SOC 7/16/18; ninety-five (95) year old female with primary diagnosis of unspecified open wound of other body part, history of falling, muscle weakness, dementia, and essential primary hypertension The Certification and Plan of Care, 3/13/19-5/11/19, failed to include a 60 day summary for the physician.

MR # 20, SOC 6/8/18; ninety (90) year old female with primary diagnosis of osteoarthritis pain in left knee, wheelchair dependent, chronic kidney disease, chronic obstructive pulmonary disease peripheral vascular disease the Certification and Plan of Care, 8/7/18-10/5/18, failed to include a 60 day summary for the physician.

MR # 21, SOC 12/23/18; fifty-seven (57) year old male with primary diagnosis of encounter for change or removal of surgical wound dressing, open wound of lower back and pelvis, pressure ulcer \ of other site stage 4, burn of left lower leg, osteomyelitis paraplegia long term use of antibiotics. The Certification and Plan of Care, 2/21/19-4/21/19, failed to include a 60 day summary for the physician.

Interview with EMP # 1 on 4/8/19 between approximately 11:30 AM-12:30 PM confirmed above findings.

















Plan of Correction:

M1009 Coordination Of Patient Services.

Elements Detailing How Deficiency will be Corrected:
An in-service will be conducted by the clinical manager and agency administrator on May 9, 2019 to stress the absolute need to comply with the State licensing requirement regarding the written summary report for each patient being sent to the attending physician at least every 60 days. During the in-service an example of a properly written 60 day summary was presented and reviewed with emphasis on completion of the form and communication with the physician regarding patient status at 60 days, a summary of all care/disciplines provided, review of patient's progress towards goals, response to treatment, status on admission and at 60 days including indication of goals that were met/not met, and a clear reason for ongoing care, if applicable. All charts with an episode ending after the statement of deficiency date will have been reviewed for the presence of a complete 60 day summary. The agency has established a process for sending the 60 day summary to the physician.

How Agency Will Act to Protect Patients in Similar Situations:
The Quality Assurance staff and clinical manager will conduct a 100% review of all clinical records for compliance with the licensing requirement regarding 60 day summaries and verification that summaries were communicated with the physician for 1 full quarter.

Measures Taken or Systems Put Into Place to Ensure Problem Does Not Recur:
100% of all records shall be reviewed for the presence of completed 60 day summaries with all required information and verification of communication with the physician for 1 full quarter. Following the first quarter, the reviews will take place quarterly with agency quarterly record review activities.


Plans To Monitor Performance To Assure Solutions Are Sustained:
A 100% compliance threshold is required. 100% review of all plans of care/change orders shall take place until threshold is met. Weekly and on-going, the Clinical Manager shall be responsible for enforcing the action necessary to correct this citation. Mandatory staff meetings and/or one-on-one counseling will be conducted by the agency Administrator in response to any issues identified during the QA audits. On-going non-compliance could be considered grounds for termination from the agency.

Date Of When The Corrective Action Will Be Completed:

Corrective action will be completed by 5/9/2019.













601.31(b) REQUIREMENT
PLAN OF TREATMENT

Name - Component - 00
601.31(b) Plan of Treatment. The
plan of treatment developed in
consultation with the agency staff
covers all pertinent diagnoses,
including:
(i) mental status,
(ii) types of services and equipment
required,
(iii) frequency of visits,
(iv) prognosis,
(v) rehabilitation potential,
(vi) functional limitations,
(vii) activities permitted,
(viii) nutritional requirements,
(ix) medications and treatments,
(x) any safety measures to protect
against injury,
(xi) instructions for timely
discharge or referral, and
(xii) any other appropriate items.
(Examples: Laboratory procedures and
any contra-indications or
precautions to be observed).

If a physician refers a patient under
a plan of treatment which cannot be
completed until after an evaluation
visit, the physician is consulted to
approve additions or modifications to
the original plan.

Orders for therapy services include
the specific procedures and modalities
to be used and the amount, frequency,
and duration.
The therapist and other agency
personnel participate in developing
the plan of treatment.

Observations:


Based upon review of agency policy, job descriptions, medical records (MR), and interview with president (EMP #1), agency failed to ensure the Registered Nurse (RN) completed a review of all medications currently taken during each home visit for seven (7) out of twenty-five (25) MR reviewed. (MR # 7, MR #9, MR # 10, MR# 11, MR #15, MR #22, MR #25) .

Findings included:

Review of agency policy titled " Contents of Plan of Care" on 4/2/19 between approximately 10:00 AM-12:00 PM , stated " The plan, shall include.... " medications and treatments"

Policy titled " Clinical Initial Assessment" stated " Comprehensive review of Medications that the patient is currently taking as well as instructions regarding name, dose, purpose, schedule, adverse reactions, side effects, drug allergies, incompatible medications/foods."

Policy titled " Plan of Care Review" stated " when a significant change in condition... new change orders are added..."

Job description for Staff Nurse/Case Manager stated " (2) Develops and implements a comprehensive goal focused, care plan.." (15) Informs the Supervising Nurse of patient services provided and ended and any changes in the Plan of Care"

Review of MR on 4/2/19 between approximately 12:15 PM-3:00 PM; 4/4/19 between 9:00 AM-11:00 AM and 12:30 PM -1:00 PM; 4/5/19 between 9:15 AM-12:00 PM and 12:30 PM-5:00 PM revealed:

MR # 7, SOC 2/27/19; nighty-two (92) year old male with primary diagnosis of hypertensive heart and chronic kidney disease with heart failure, chronic kidney disease stage 3 chronic combined systolic and diastolic (congestive) heart failure, old heart attach, chronic atrial fibrillation chronic obstructive pulmonary disease atherosclerotic heart disease of native coronary artery
The Certification and Plan of Care, 2/27/19-4/27/19.
Physician's order, " coumadin as ordered".
Does not list the dose, route, frequency, purpose, schedule, adverse reactions, side effects.
Order, " hold coumadin as ordered ".
Does not list the specific order parameters for when to hold and when to administer in addition to not listing dose, route, frequency, purpose, schedule, adverse reactions, side effects.
Order," hold medications as ordered".
Does not list the specific order parameters for when to hold and when to administer in addition to not listing dose, route, frequency, purpose, schedule, adverse reactions, side effects.
Order," medications as ordered".
Does not list the specific order parameters for when to administer in addition to not listing the specific medication, dose, route, frequency, purpose, schedule, adverse reactions, side effects.
Order, " pt/inr checkced as ordered".
Does not list the specific order for PT/ INR testing, how often the PT/ INR is to be taken, what parameters to notify physician.

MR # 9, SOC 10/26/18; seventy-seven (77) year old female with primary diagnosis of general epilepsy rheumatoid arthritis with rheumatoid factor fibromyalgia history of falling, encounter for issue of repeat prescription
The Certification and Plan of Care, 2/23/19-4/23/19, failed to include nursing orders for Subcutaneous (SQ) injection Medication order " Enbrel \ \ solution for injection subcutaneous \ qw \ " this order does not list the dose to be administered.

MR # 10, SOC 3/16/19; sixty-three (63) year old female with primary diagnosis of encounter for adjustment and management of peripherally inserted central catheter (picc) line encounter for issue of repeat prescription abscess of intestine perforation of intestine kidney stone, essential hypertension gastro-esophageal reflux disease
The Certification and Plan of Care, 3/16/19-5/14/19, failed to include complete IV medication order including:
the order " Ertapenem \ 1G/100 ML" \ does not list dose, frequency, route to be administered, purpose, schedule, adverse reactions, side effects.


MR # 11, SOC 12/31/18; eighty-five (85) year old male with primary diagnosis of respiratory failure pneumonia, dependent on supplemental oxygen, vascular dementia epilepsy prosthetic heart valve The Certification and Plan of Care, 3/1/19-4/29/19, failed to include complete medication orders including:
" Iron 325 mg qd no route of administration listed, purpose, schedule, adverse reactions, side effects.
patient on continuous oxygen and oxygen was not documented on medication section of certification and plan of care nor was the dose, route, frequency order present.



MR # 15, SOC 2/4/19; ninety (90) year old female with primary diagnosis of hemiplegia a stroke, aphasia difficulty walking, falling, chronic pain syndrome essential primary hypertension anxiety disorder
The Certification and Plan of Care dated 2/4/19-4/4/19. The patient was admitted to the hospital on 2/18/19 and was not discharged from the hospial until 4/1/19, six (6) weeks later, when a Resumption of Care (ROC) skilled nursing visit was conducted. The agency failed to obtain or show evidence of physician orders including an updated medication list upon discharge from hospital.

MR # 22, SOC 1/20/18; fifty-one (51) year old female with primary diagnosis of encounter for change or removal of surgical wound dressing, non pressure chronic ulcer lower limb, lymphedema pain in right leg, morbid obesity, personal history of other venous thrombosis and embolism osteoarthritis
The Certification and Plan of Care was 10/28/18-12/26/18 with medications listed:
" Citalopram \ 40 mg daily" no route listed.
"Coumadin \ 3 mg tablet every other day" no route listed.
"Diltiazem \ 60 mg twicw daily" no route listed.
"gabapentin \ 100 mg twice daily" no route listed.


. The patient was admitted to the hospital on 11/25/18 and was discharged from the hospital on 11/30/18 ( six (6) days) later with agency failing to obtain or show evidence of physician orders, including an updated medication list, upon resuming care and services.
Patient was readmitted to the hospital on 12/2/18 and discharged from the hospital on 12/8/18 (six (6) days) later with agency failing to obtain or show evidence of physician orders, including an updated medication list, upon resuming care and services.


MR # 25, SOC 3/22/19; eighty-seven (87) year old female with primary diagnosis of encounter for adjustment and management of peripherally inserted central line catheter, encounter for issue of repeat prescription, pneumonia sepsis chronic respiratory failure dependent on supplemental oxygen, type 2 diabetes
The Certification and Plan of Care, 3/22/19-5/20/19, failed to include:
complete IV medication order including:
the order " Ceftriaxone \ 2G/50 ML" \ solution for injection intravenous qd \ does not list dose to be administered, purpose, schedule, adverse reactions, side effects.


Interview with EMP # 1 on 4/8/19 between approximately 11:30 AM-12:30 PM confirmed above findings.















Plan of Correction:

M 1018 Plan Of Treatment
Elements Detailing How Deficiency will be Corrected:
An in-service will be conducted by the Administrator and Clinical Manager on May 9, 2019 to address the current Statement of Deficiencies. It has been noted that multiple deficiencies have been cited relative the physician's plan of care. The In-service detailed multiple missing items from the plan as addressed in the Statement of Deficiencies. A copy of the plan of care section of 2018 CoPs will be provided to all professional staff as well as agency policy on completion of the POC. Specificity of orders was highlighted to all staff. It is unacceptable to write "as ordered" on the order or in subsequent documentation. Must list specific medication, dose, route, frequency, purpose, schedule, adverse reactions, side effects. Must list the specific order for PT/INR testing, how often the PT/INR is to be taken, what parameters to notify physician. Will be instructed on the use of parameters for all measurable items-such as vital signs, notification of physician, etc. Staff will be given specific direction on the appropriate documentation on all orders in medical record of medications-i.e. correct spelling of med; dose; route of administration. Instruction on the reconciliation of all meds will be provided as well as instruction to be given to patients on new and changed medications. Instruction shall include purpose of medication, adverse reactions to be aware of as well as potential side effects.

How Agency Will Act to Protect Patients in Similar Situations:
All clinical documentation for all patients shall be reviewed for corrective action on items identified on the statement of deficiencies. QA shall review 100% of all documentation for proper documentation on the plan of care and subsequent documentation by all professional staff members. Follow-up in-services shall be conducted at least monthly until documentation errors are resolved.

Measures Taken or Systems Put Into Place to Ensure Problem Does Not Recur:
100% of all plans of care and change orders shall be reviewed at SOC, ROC and Recertification and at any time an update is made (until at least 90% overall compliance is achieved) to ensure that complete and accurate orders have been documented. Conferences with individual staff members (nurses/therapists) related to the need for correction of identified deficiencies shall be documented and available for review. Individual counseling items shall be filed in the personnel record of individual staff member.

Plans To Monitor Performance To Assure Solutions Are Sustained:
A 100% compliance threshold is required. 100% review of all plans of care/change orders shall take place until threshold is met. Weekly and on-going, the Clinical Manager shall be responsible for enforcing the action necessary to correct this citation. Mandatory staff meetings and/or one-on-one counseling will be conducted by the agency Administrator in response to any issues identified during the QA audits. On-going non-compliance could be considered grounds for termination from the agency.

Date Of When The Corrective Action Will Be Completed:

Corrective action will be completed by 5/9/2019.






601.31(d) REQUIREMENT
CONFORMANCE WITH PHYSICIAN'S ORDERS

Name - Component - 00
601.31(d) Conformance With
Physician's Orders. All prescription
and nonprescription (over-the-counter)
drugs, devices, medications and
treatments, shall be administered by
agency staff in accordance with the
written orders of the physician.
Prescription drugs and devices shall
be prescribed by a licensed physician.
Only licensed pharmacists shall
dispense drugs and devices. Licensed
physicians may dispense drugs and
devices to the patients who are in
their care. The licensed nurse or
other individual, who is authorized by
appropriate statutes and the State
Boards in the Bureau of Professional
and Occupational Affairs, shall
immediately record and sign oral
orders and within 7 days obtain the
physician's counter-signature. Agency
staff shall check all medicines a
patient may be taking to identify
possible ineffective drug therapy or
adverse reactions, significant side
effects, drug allergies, and
contraindicated medication, and shall
promptly report any problems to the
physician.

Observations:




Based upon review of agency policy, job descriptions, medical records (MR), skilled visit notes, and interview with president (EMP #1), agency failed to ensure the skilled nursing staff followed the plan of care or obtained updated physician orders for nineteen (19) of twenty-five (25) records reviewed. (MR # 1, MR #2 MR #5, MR #8, MR # 9, MR # 10, MR #11-17, MR # 19, MR # 20, MR # 21, MR #22, MR #24, MR # 25).

Findings included:

Review of agency policy titled " Contents of Plan of Care" on 4/2/19 between approximately 10:00 AM-12:00 PM , stated " The plan, shall include.... " Types, amount, and duration of services; frequency of visits; equipment required; goals, prognosis, and rehabilitation potential; functional limitations/activities permitted; nutritional requirements; medications and treatments; safety measures to protect against injury; other appropriate items; and orders for therapy services to be provided include the following: specific procedures to be used; specific modalities to be used; amount; frequency; and duration".

Policy titled " Clinical Initial Assessment" stated " Comprehensive review of Medications that the patient is currently taking as well as instructions regarding name, dose, purpose, schedule, adverse reactions, side effects, drug allergies, incompatible medications/foods."

Policy titled " Start of Care Documents" stated " The following is the documentation requirements for the Start of Care Assessment: Patient problem list; Patient goal list; name of physician contacted for the confirmation of the Plan of Care"; Interventions performed..."

Policy titled " Plan of Care Review" stated " when a significant change in condition... new change orders are added..."

Job description for Staff Nurse/Case Manager stated " (2) Develops and implements a comprehensive goal focused, care plan.." (15) Informs the Supervising Nurse of patient services provided and ended and any changes in the Plan of Care"


Review of MR on 4/2/19 between approximately 12:15 PM-3:00 PM; 4/4/19 between 9:00 AM-11:00 AM and 12:30 PM -1:00 PM; 4/5/19 between 9:15 AM-12:00 PM and 12:30 PM-5:00 PM revealed:

MR # 1, Start of Care (SOC) 3/15/19; ninety (90) year old male with primary diagnosis of pressure ulcer of left heel, pressure ulcer of sacral area, muscle weakness, and Diabetes; Certification period: 3/15/19-5/13/19.
Plan of treatment failed to include wound care orders for left heel and also sacral area; no aide care plan established.

MR # 2, SOC 12/28/18; ninety-three (93) year old female with primary diagnosis of encounter for change or removal of nonsurgical wound dressing, non pressure ulcer of right heel, non pressure chronic ulcer of right ankle, peripheral vascular disease (circulatory vascular disease with narrowed arteries and decreased blood flow), muscle weakness. The dated, 12/27/18 read, " Please provide daily dressing changes x 1 wk until follow up with \ 1/3/19. 1. Clean wounds with wound cleanser, 2. Maxorb extra ag to R dorsal foot wound and medial ankle wound and L medial foot wound, 3. cover sponge, 4. gauze roll, 5. single Tubigrip layer D"
Certification period: 12/28/18-2/25/19:
Plan failed to carry over wound care treatment orders from 12/27/18 with no specific treatment orders documented.
Telephone verbal order dated, 1/17/19, read, " Please continue c \ daily dsg \ changes to L foot, Santyl to wound bed ..cover sponge, abd, gauze roll. Will discontinue Mepilex donut for offloading a \ this time since pt not wearing a shoe. R
medial foot Mepilex border lite. Single layer Tubigrip D to both lower legs."
TVO dated 2/21/19, read, " continue every other day dressing changes to all wounds."
Certification period: 2/25/19-4/25/19, failed to carry over wound care treatment orders from 1/17/19 or 2/21/19 with no specific treatment orders documented.
patient was hospitalized and no resumption of care orders were obtained for skilled nursing including wound care orders or physical therapy orders.


MR # 5, SOC 3/4/19; sixty-six (66) year old female with primary diagnosis of cutaneous abscess of right foot unspecified open wound in right foot, cellulitis of right lower limb change or removal non surgical wound dressing, atherosclerotic heart disease of native coronary artery
Physician orders, given at time of referral on 3/1/19, stated " Dressing- Iodoform packing 1/4 inch R \ foot daily S/P \ I.D.\ 2/28/19"
Certification period: 3/4/19-5/2/19, failed to carry over wound care treatment orders from 3/1/19 with no specific treatment orders documented.


MR # 8, SOC 3/15/19; eight -four (84) year old male with primary diagnosis of malignant neoplasm of unspecified main bronchus secondary neoplasm of bone and bone marrow, neoplasm of liver and bile duct, unspecified atrial fibrillation pacemaker, difficulty walking. Certification period: 3/15/19-5/13/19, failed to include order for medical social worker ( MSW).


MR # 9, SOC 10/26/18; seventy-seven (77) year old female with primary diagnosis of general epilepsy rheumatoid arthritis with rheumatoid factor fibromyalgia history of falling, encounter for issue of repeat prescription Certification Period: 2/23/19-4/23/19, failed to include nursing orders for administering Subcutaneous (SQ) injection order for PT/ INR or order for Occupational Therapist.

MR # 10, SOC 3/16/19; sixty-three (63) year old female with primary diagnosis of encounter for adjustment and management of peripherally inserted central catheter (picc) line encounter for issue of repeat prescription abscess of intestine perforation of intestine kidney stone, essential hypertension gastro-esophageal reflux disease Certification Period: 3/16/19-5/14/19, failed to include complete IV medication order "Ertapenem \ 1 G/100 ML missing route, frequency, no orders for PICC \ line care, measurement of arm circumference, measuring length of catheter to assess migration, no order for lab draws including type of tube, frequency, when to report to physician.

MR # 11, SOC 12/31/18; eighty-five (85) year old male with primary diagnosis of respiratory failure pneumonia, dependent on supplemental oxygen, vascular dementia epilepsy prosthetic heart valve
Certifcation Period: 3/1/19-4/29/19, failed to include lab draws including type of tube, frequency, sign or symptms to report to physician; physical therapy order only states " continue plan of care" but failed to include specific orders.


MR # 12, SOC 4/1/19; seventy-four (74) year old female with primary diagnosis of encounter of surgical aftercare following surgery on digestive system, acquired absence of other specified parts of digestive tract, malignant neoplasm \ of colon, secondary malignant neoplasm of liver and bile duct.
Certification Period: 4/1/19-5/30/19, failed to include wound vac care orders for prepping skin or weekly cannister changes.

MR # 13, SOC 7/16/18; ninety-five (95) year old female with primary diagnosis of unspecified open wound of other body part, history of falling, muscle weakness, dementia, and essential primary hypertension
Cerification Period: 3/13/19-5/11/19, failed to include wound care orders for head wound.

MR # 14, SOC 3/3/19; sixty-two (62) year old female with primary diagnosis of non-pressure chronic ulcer of unspecified part of right lower leg, cellulitis encounter for change or removal of nonsurgical wound dressing, sepsis enterocolitis essential primary hypertension atrial fibrillation
Certification Period: 3/3/19-5/1/19, failed to include wound care orders.

MR # 15, SOC 2/4/19; ninety (90) year old female with primary diagnosis of hemiplegia a stroke, aphasia difficulty walking, falling, chronic pain syndrome essential primary hypertension anxiety disorder
Certification Period: 2/4/19-4/4/19. failed to include orders to resume care on 4/1/19 including skilled nursing and physical therapy services. Patient was hospitalized 2/18/19-3/31/19,


MR # 16, SOC 3/7/19; seventy-two (72) year old male with primary diagnosis of fracture of sacrum kissing spine low back pain, rheumatoid arthritis weakness, lymphedema prostatic hyperplasia
The Certification and Plan of Care, 3/7/19-5/5/19, failed to include physical therapy orders for treatment and goals.

MR # 17, SOC 2/13/19; seventy-one (71) year old male with primary diagnosis of fracture of humerus history of falling, atherosclerotic heart disease of native coronary artery essential primary hypertension atrial fibrillation nicotine dependence.
Certification Period: 2/13/19-4/13/19, failed to include orders for Physical Therapy and Home Health Aide services.


MR # 19, SOC 11/9/18; eighty-four (84) year old male with primary diagnosis of aftercare following joint replacement, fracture of femur artificial left hip, pain in left hip, history of falling, dementia chronic obstructive pulmonary disease
Certification Period: 11/9/18-1/7/19, failed to include physical therapy discharge orders for 12/26/19.

MR # 20, SOC 6/8/18; ninety (90) year old female with primary diagnosis of osteoarthritis pain in left knee, wheelchair dependent, chronic kidney disease, chronic obstructive pulmonary disease peripheral vascular disease
Certification Period: 8/7/18-10/5/18, failed to include orders for Physical Therapy services.

MR # 21, SOC 12/23/18; fifty-seven (57) year old male with primary diagnosis of encounter for change or removal of surgical wound dressing, open wound of lower back and pelvis, pressure ulcer \ of other site stage 4, burn of left lower leg, osteomyelitis paraplegia long term use of antibiotics. Certification Period: 12/23/18-2/20/19, orders read, " SN to instruct PT/CG \ in wound care/suture line care: WTD \ daily to left lateral leg".
Order failed to include what solution to use, sterile or aseptic technique, what supplies were needed such as gloves and wound care supplies or how often to complete wound measurements.
No order for when to contact the physician.
Certification Period: 2/21/19-4/21/19, orders read, " SN to instruct PT/CG \ in wound care/suture line care: " WTD \ change daily to left lateral leg" order failed to include what solution to use, sterile or aseptic technique, what supplies were needed such as gloves and wound care supplies or how often to complete wound measurements.
No order for when to contact the physician.


MR # 22, SOC 1/20/18; fifty-one (51) year old female with primary diagnosis of encounter for change or removal of surgical wound dressing, non pressure chronic ulcer lower limb, lymphedema pain in right leg, morbid obesity, personal history of other venous thrombosis and embolism osteoarthritis Certification Period: 10/28/18-12/26/18: Orders read, " PT/INR checks as directed". No specific dates/times. No specified parameters for when to contact the physician with lab results.
Skilled nursing frequency: 1-2 x week x 60 days; 10 prn visits for wound care" and 60 day summary: " receiving SN \ services for wound care to non-healing chronic venous stasis ulcer"
physician orders were not obtained for skilled nursing to resume care and services on 11/30/18 including wound care and/or PT INR bloodwork.
Physician orders were not obtained for skilled nursing or physical therapy services to resume care on 12/8/18 including wound care and/ or PT INR bloodwork.

MR # 24, SOC 2/19/19; eighty-three (83) year old female with primary diagnosis of atrial fibrillation long term use of anticoagulants, muscle weakness, hypertensive chronic kidney disease type 2 diabetesdifficulty walking.
Certification Period: 2/19/19-4/19/19. Physician orders failed to include physical therapy services with frequency.

MR # 25, SOC 3/22/19; eighty-seven (87) year old female with primary diagnosis of encounter for adjustment and management of peripherally inserted central line catheter, encounter for issue of repeat prescription, pneumonia sepsis chronic respiratory failure dependent on supplemental oxygen, type 2 diabetes Certification Period: 3/22/19-5/20/19. Physicians orders read, " perform PICC care". no frequency of dressing change; parameters to contact physician; arm measurement or length of PICC tubing. No orders for blood work.


Interview with EMP # 1 on 4/8/19 between approximately 11:30 AM-12:30 PM confirmed above findings.






Plan of Correction:



M 1020 Conformance With Physician's Orders.

Elements Detailing How Deficiency will be Corrected:
An in-service will be held on May 9, 2019 conducted by the Agency Administrator and Clinical Manager re: Conformance with physician orders. The professional staff will be issued copies of guidelines relative to this Standard as well as copy of agency policy outlining requirements for securing orders from the physician and job descriptions outlining responsibilities for all physician orders, treatments and medications.
Additional items instructed upon will be the absolute requirement for the specific wound care ordered by the physician, assuring aide care plans are complete prior to the assignment of the aide. In-services shall be held monthly to review progress for at least one quarter.

How Agency Will Act to Protect Patients in Similar Situations:
The QA staff under the direction of the Clinical manager, shall be responsible for an entire record review for each new admission, resumption of care and recertification in the agency. 100% of all records shall be reviewed for compliance in all areas required by CoPs and Agency Policy. A report by the QA staff will be submitted to the Clinical Manager at least weekly. A summary of findings shall be submitted to the Administrator on a monthly basis for at least one full quarter.

Measures Taken or Systems Put Into Place to Ensure Problem Does Not Recur:
100% of all plans of care and change orders shall be reviewed at SOC, ROC and Recertification and at any time an update is made (until at least 90% overall compliance is achieved) to ensure that complete and accurate orders have been documented. Conferences with individual staff members (nurses/therapists) related to the need for correction of identified deficiencies shall be documented and available for review. Individual counseling items shall be filed in the personnel record of individual staff member.


Plans To Monitor Performance To Assure Solutions Are Sustained:
A 100% compliance threshold is required.100% review of all plans of care/change orders shall take place until threshold is met. Weekly and on-going, the Clinical Manager shall be responsible for enforcing the action necessary to correct this citation. Mandatory staff meetings and/or one-on-one counseling will be conducted by the agency Administrator in response to any issues identified during the QA audits. On-going non-compliance could be considered grounds for termination from the agency.

Date Of When The Corrective Action Will Be Completed:

Corrective action will be completed by 5/9/2019.




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 upon review of agency policy, job descriptions, medical records (MR), and interview with president (EMP #1), agency failed to ensure the Registered Nurse (RN) completed a review of all medications currently taken during each home visit for seven (7) out of twenty-five (25) MR reviewed. (MR # 7, MR #9, MR # 10, MR# 11, MR #15, MR #22, MR #25) .

Findings included:

Review of agency policy titled " Contents of Plan of Care" on 4/2/19 between approximately 10:00 AM-12:00 PM , stated " The plan, shall include.... " medications and treatments"

Policy titled " Clinical Initial Assessment" stated " Comprehensive review of Medications that the patient is currently taking as well as instructions regarding name, dose, purpose, schedule, adverse reactions, side effects, drug allergies, incompatible medications/foods."

Policy titled " Plan of Care Review" stated " when a significant change in condition... new change orders are added..."

Job description for Staff Nurse/Case Manager stated " (2) Develops and implements a comprehensive goal focused, care plan.." (15) Informs the Supervising Nurse of patient services provided and ended and any changes in the Plan of Care"

Review of MR on 4/2/19 between approximately 12:15 PM-3:00 PM; 4/4/19 between 9:00 AM-11:00 AM and 12:30 PM -1:00 PM; 4/5/19 between 9:15 AM-12:00 PM and 12:30 PM-5:00 PM revealed:

MR # 7, SOC 2/27/19; nighty-two (92) year old male with primary diagnosis of hypertensive heart and chronic kidney disease with heart failure, chronic kidney disease stage 3 chronic combined systolic and diastolic (congestive) heart failure, old heart attach, chronic atrial fibrillation chronic obstructive pulmonary disease atherosclerotic heart disease of native coronary artery
The Certification and Plan of Care, 2/27/19-4/27/19.
Physician's order, " coumadin as ordered".
Does not list the dose, route, frequency, purpose, schedule, adverse reactions, side effects.
Order, " hold coumadin as ordered ".
Does not list the specific order parameters for when to hold and when to administer in addition to not listing dose, route, frequency, purpose, schedule, adverse reactions, side effects.
Order," hold medications as ordered".
Does not list the specific order parameters for when to hold and when to administer in addition to not listing dose, route, frequency, purpose, schedule, adverse reactions, side effects.
Order," medications as ordered".
Does not list the specific order parameters for when to administer in addition to not listing the specific medication, dose, route, frequency, purpose, schedule, adverse reactions, side effects.
Order, " pt/inr checkced as ordered".
Does not list the specific order for PT/ INR testing, how often the PT/ INR is to be taken, what parameters to notify physician.

MR # 9, SOC 10/26/18; seventy-seven (77) year old female with primary diagnosis of general epilepsy rheumatoid arthritis with rheumatoid factor fibromyalgia history of falling, encounter for issue of repeat prescription
The Certification and Plan of Care, 2/23/19-4/23/19, failed to include nursing orders for Subcutaneous (SQ) injection Medication order " Enbrel \ \ solution for injection subcutaneous \ qw \ " this order does not list the dose to be administered.

MR # 10, SOC 3/16/19; sixty-three (63) year old female with primary diagnosis of encounter for adjustment and management of peripherally inserted central catheter (picc) line encounter for issue of repeat prescription abscess of intestine perforation of intestine kidney stone, essential hypertension gastro-esophageal reflux disease
The Certification and Plan of Care, 3/16/19-5/14/19, failed to include complete IV medication order including:
the order " Ertapenem \ 1G/100 ML" \ does not list dose, frequency, route to be administered, purpose, schedule, adverse reactions, side effects.


MR # 11, SOC 12/31/18; eighty-five (85) year old male with primary diagnosis of respiratory failure pneumonia, dependent on supplemental oxygen, vascular dementia epilepsy prosthetic heart valve The Certification and Plan of Care, 3/1/19-4/29/19, failed to include complete medication orders including:
" Iron 325 mg qd no route of administration listed, purpose, schedule, adverse reactions, side effects.
patient on continuous oxygen and oxygen was not documented on medication section of certification and plan of care nor was the dose, route, frequency order present.



MR # 15, SOC 2/4/19; ninety (90) year old female with primary diagnosis of hemiplegia a stroke, aphasia difficulty walking, falling, chronic pain syndrome essential primary hypertension anxiety disorder
The Certification and Plan of Care dated 2/4/19-4/4/19. The patient was admitted to the hospital on 2/18/19 and was not discharged from the hospial until 4/1/19, six (6) weeks later, when a Resumption of Care (ROC) skilled nursing visit was conducted. The agency failed to obtain or show evidence of physician orders including an updated medication list upon discharge from hospital.

MR # 22, SOC 1/20/18; fifty-one (51) year old female with primary diagnosis of encounter for change or removal of surgical wound dressing, non pressure chronic ulcer lower limb, lymphedema pain in right leg, morbid obesity, personal history of other venous thrombosis and embolism osteoarthritis
The Certification and Plan of Care was 10/28/18-12/26/18 with medications listed:
" Citalopram \ 40 mg daily" no route listed.
"Coumadin \ 3 mg tablet every other day" no route listed.
"Diltiazem \ 60 mg twicw daily" no route listed.
"gabapentin \ 100 mg twice daily" no route listed.


. The patient was admitted to the hospital on 11/25/18 and was discharged from the hospital on 11/30/18 ( six (6) days) later with agency failing to obtain or show evidence of physician orders, including an updated medication list, upon resuming care and services.
Patient was readmitted to the hospital on 12/2/18 and discharged from the hospital on 12/8/18 (six (6) days) later with agency failing to obtain or show evidence of physician orders, including an updated medication list, upon resuming care and services.


MR # 25, SOC 3/22/19; eighty-seven (87) year old female with primary diagnosis of encounter for adjustment and management of peripherally inserted central line catheter, encounter for issue of repeat prescription, pneumonia sepsis chronic respiratory failure dependent on supplemental oxygen, type 2 diabetes
The Certification and Plan of Care, 3/22/19-5/20/19, failed to include:
complete IV medication order including:
the order " Ceftriaxone \ 2G/50 ML" \ solution for injection intravenous qd \ does not list dose to be administered, purpose, schedule, adverse reactions, side effects.


Interview with EMP # 1 on 4/8/19 between approximately 11:30 AM-12:30 PM confirmed above findings.














Plan of Correction:

M 1023 Duties of a Registered Nurse.

Elements Detailing How Deficiency will be Corrected:
Individual meetings with each registered nurse will take place to review job descriptions and RN Standards of Practice. Each nurse will be provided the opportunity to review his/her individual job description. Clinical records for each individual nurse will be reviewed. It is unacceptable to write "as ordered" on the order or in subsequent documentation. Must list specific medication, dose, route, frequency, purpose, schedule, adverse reactions, side effects. Must list the specific order for PT/INR testing, how often the PT/INR is to be taken, what parameters to notify physician. Nurses will be required to attend monthly in-services conducted by the clinical manager until all clinical documentation has been corrected. A new/upgraded QA process has been put into place and will begin on 5/9/2019. Orientation for all newly hired staff shall include documentation principles and instruction.

How Agency Will Act to Protect Patients in Similar Situations:
100% of all documentation submitted to the agency shall be reviewed for compliance with this Standard, agency policy and Standards of Practice for Registered Nurses in the State. QA shall report individual staff members in non-compliance to the clinical manager at least weekly. The clinical manager shall submit a summary of the report to the Agency Administrator at least monthly or sooner if there is consistent noncompliance by a staff member.

Measures Taken or Systems Put Into Place to Ensure Problem Does Not Recur:
100% of all plans of care and change orders shall be reviewed at SOC, ROC and Recertification and at any time an update is made (until at least 90% overall compliance is achieved) to ensure that complete and accurate orders have been documented. Conferences with individual staff members (nurses/therapists) related to the need for correction of identified deficiencies shall be documented and available for review. Individual counseling items shall be filed in the personnel record of individual staff member.



Plans To Monitor Performance To Assure Solutions Are Sustained:
A 100% compliance threshold is required. 100% review of all plans of care/change orders shall take place until threshold is met. Weekly and on-going, the Clinical Manager shall be responsible for enforcing the action necessary to correct this citation. Mandatory staff meetings and/or one-on-one counseling will be conducted by the agency Administrator in response to any issues identified during the QA audits. On-going non-compliance could be considered grounds for termination from the agency.

Date Of When The Corrective Action Will Be Completed:

Corrective action will be completed by 5/9/2019.






Initial Comments:

Based on the findings of an unannounced on-site home health Medicare re-certification and state re-licensure survey conducted between 4/2/19 through 4/9/19, Community Home Health Care, Inc. was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.






Plan of Correction:




Initial Comments:

Based on the findings of an unannounced on-site home health Medicare re-certification and state re-licensure survey conducted between 4/2/19 through 4/8/19, Community Home Health Care, Inc. was found to be in compliance with the requirements of 35 P. S.448.809 (b).






Plan of Correction: