QA Investigation Results

Pennsylvania Department of Health
ALMA HEALTH SKILLED SERVICES LLC
Health Inspection Results
ALMA HEALTH SKILLED SERVICES LLC
Health Inspection Results For:


There are  9 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:


Based upon an unannounced on-site home care agency state relicensure survey conducted between 5/3/19-5/7/19, Alma Health Skilled Services LLC. was found to be not in compliance with the requirements of 28 PA Code, Health Facilities, Part IV, Chapter 601, Subpart H, Homecare Agencies and Home Care Registries.








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 agency policy, personnel files (PF), and interview with Director of Nursing (DON) ( PF # 4), agency failed to show evidence of orientation for two (2) of two (2) files reviewed. ( PF # 2, PF # 5).

Findings included:

Policy review on 5/7/19 at approximately 2:00 PM-2:45 PM titled " Personnel orientation, Policy # : 10007.1 ", stated " Personnel will be required to attend an orientation program upon employment." (4.) " An Orientation checklist... will be completed for each new employee."

Review of PF on 5/3/19, between approximately 11:00 AM-11:45 Am and 12:15 PM-1:00 PM revealed:

PF # 2, Date of Hire (DOH) 4/23/18; no completed orientation checklist was present.

PF # 5, DOH 1/30/19; no completed orientation checklist was present.

Interview with PF # 4 on 5/7/19 at approximately 2:45 PM confirmed above findings.







Plan of Correction:

On 5/8/19: QAPI Director review was completed for PF#2. The document overlooked at the time of Orientation on 04/23/18, discovered missing by DOH on 05/7/19 was identified. On 5/10/19: employee related to PF#2 regarding missing orientation checklist was educated by DON and QAPI Director to on the content and use of the form as a self awareness and measuring of any given clinicians skill set. Moreover, should have been completed as part of orientation on the date of hire 04/23/18 and then on a consecutive yearly basis thereafter. As a result will be completed on 5/23/19 as intended yearly moving forward.
PF # 5, DOH 1/30/19; no completed orientation checklist was present. Interview with PF # 4 on 5/7/19 at approximately 2:45 PM confirmed above findings. Initial Correction for PF#5 finding : On 5/8/19: QAPI Director review was completed for PF#5. The same document was overlooked at the time of Orientation on 1/30/19, discovered missing by DOH on 05/7/19 was identified. On 5/13/19: employee related to PF#5 regarding missing orientation checklist was provided education by QAPI Director to on the content and use of the form as a self awareness and measuring of any given clinicians skill set and should have been completed as part of orientation on the date of hire 1/30/19 and then on a consecutive yearly basis thereafter. In recognition of Best Practice, the documents were completed and returned 5/20/19, and will be yearly after that date rather than wait until 1/30/2020 All personnel files were audited by QAPI director. Orientation checklist has been added to orientation paperwork as well as policy and procedure manual. All new employee files to be audited for completeness by DON/Designee.


601.22(d) REQUIREMENT
CLINICAL RECORD REVIEW

Name - Component - 00
601.22(d) Clinical Record Review. At
least quarterly, appropriate health
professionals, representing at least
the scope of the program, review a
sample of both active and closed
clinical records to assure that
established policies are followed in
providing services (direct as well as
services under arrangement). There is
a continuing review of clinical
records for each 60-day period that a
patient receives home health services
to determine adequacy of the plan of
treatment and appropriateness of
continuation of care.

Observations:


Based upon review of agency policy, Quality Assurance and Performance Improvement (Qapi) documents, and interview with Director of Nursing (DON) ( PF # 4), agency failed to show evidence of quarterly chart reviews being conducted by representation from all disciplines providing care for two (2) of two (2) years reviewed. (2018 and 2019).

Findings included:

Policy review on 5/7/19 at approximately 2:00 PM-2:45 PM titled " Client/Patient Record Review, Policy # : 7-013.2 ", stated " Quarterly Review: (3. B.) The sample will represent the agency's services and will be proportionate to the area's service mix."

Review of Qapi documents on 5/3/19, between approximately 9:45 AM-11:00 AM revealed:

Year 2018 nursing and physical therapy services were both provided to patients. Quarterly record reviews did not include both disciplines.

Year 2019 nursing and physical therapy services were both provided to patients. Quarterly record reviews did not include both disciplines.

Interview with PF # 4 on 5/7/19 at approximately 2:45 PM confirmed above findings.









Plan of Correction:

Physical therapist to be involved with and contribute to quarterly record reviews and QAPI process. Therapist to sit on PAC board. Therapist advised and accepted on 5/22/19 of his responsibility to review quarterly records as well as sitting on and his role while on the PAC board. A therapist will maintain a seat on PAC board at all times.
COO/Designee to monitor for continued compliance.


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, medical records (MR), and interview with Director of Nursing (DON) ( PF # 4), agency failed to include all elements required in the Plan of Treatment (POT) for four (4) of four (4) files reviewed ( MR # 1; MR # 4; MR # 6; MR # 8).

Findings included:

Policy review on 5/7/19 at approximately 2:00 PM-2:45 PM titled " Clinical Management and Service Planning Process Policy # 4-001.2, " stated " (3.) ... the service delivery plan will include ... (e.) Type of services and frequency and duration of shifts. ( f.) Equipment and supplies... (5.) The skilled service delivery plan will be based upon physician orders.."

Review of MR on 5/3/19, between approximately 1:00 PM -3:00 PM and 5/7/19 between approximately 8:45 AM-12:00 PM revealed:

MR # 1, Start of Care (SOC) 4/30/19; sixty-four (64) year old female with diagnosis of arthritis ( swollen joint) of left knee ; encounter for orthopedic after care ( knee replacement);

Physician orders 4/30/19-6/28/19 with skilled nursing order to administer "Cefazolin in Sodium Chloride IV 50 ml \ every eight (8) hours using SASH \ method".
Medication list on the Physician orders failed to include order for Heparin.

MR # 4, SOC 1/26/19; eighty-one (81) year old male with diagnosis of atherosclerosis heart disease type 2 diabetes orders for episode: 1/26/19-3/26/19, "physical therapy services 3 x/week, 4 weeks".
Patient was in hospital, returned home on 2/18/19. Documentation showed a Physician verbal order on 2/17/19 to resume PT \ services.
No documented physician's order for specific therapy interventions.

Physician orders for episode: 3/27/19-5/25/19, "physical therapy services order PT to assess/eval and treat".

No specific orders for PT duration and/or frequency.

MR # 6, SOC 9/28/18; sixty-eight (68) year old female with diagnosis of chronic peripheral \ venous insufficiency pressure ulcer orders for episode: 1/26/19-3/26/19 " resume \ skilled nursing services effective 2/11/19."
No specific skilled nursing orders written for resumption of care including frequency or interventions.
Nursing care provided on: 2/11/19, 2/15/19, 2/22/19, 2/28/19, 3/6/19, 3/26/19.


MR # 8, SOC 2/24/19; seventy-eight (78) year old female with diagnosis of infection following a procedure; sepsis hypertension
Physician orders for episode: 2/24/19-4/24/19, "skilled nursing services 2x/wk x 9 wks, 3 PRN for changes in condition". Provide wound care, dressing change for patient as per MD order". "Wound care procedure: Warm water and soap to clean. Pat dry with clean towel. Do not rub. may remove dressing if not drainage and shower."
Order did not include area of wound, specific criteria regarding when to contact physician in relation to the wound care, how often wound measurements should be done.

Interview with PF # 4 on 5/7/19 at approximately 2:45 PM confirmed above findings.






























Plan of Correction:

No harm came to any patient due to Plan of treatment not being followed.
MR#1- Heparin was placed on Medication profile 5/8/19 and new medication profile faxed to physician.
MR #4-Order sent to physician 5/22/19 that frequency not followed for both cert periods as well as orders did not have specific therapy interventions.
MR#6-Communication note placed in patients' chart and faxed to physician 5/22/19 that patients resumption of care order did specify frequency or interventions for SN.
MR#8-Orders had previously been written for issues found on chart review to include extra visits. Communication note sent to MD 5/22/19 detailing where wound was and that it should have been measured weekly as well as when to call physician.
All staff educated on 5/22/19 on following frequencies, writing complete detailed orders to include resumption of care orders, doing missed visit notes and faxing them to physician as well as writing orders for extra visits made, and compiling accurate medication profiles.
DON/Designee to audit 3 active charts per week for 2 weeks and then 2 active charts per week for 4 weeks. All discharged charts to be reviewed by QAPI manager.



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, medical records (MR), and interview with Director of Nursing (DON) ( PF # 4), agency staff failed to follow physician orders for three (3) of three (3) files reviewed ( MR # 2; MR # 4; MR # 6).

Findings included:

Policy review on 5/7/19 at approximately 2:00 PM-2:45 PM titled " Clinical Management and Service Planning Process, Policy # 4-001.1, " stated "(3. B.) The service delivery plan will include: Specific services to be provided."

Review of MR on 5/3/19, between approximately 1:00 PM -3:00 PM and 5/7/19 between approximately 8:45 AM-12:00 PM revealed:

MR # 2, Start of Care (SOC) 4/11/19; thirty-four (34) year old female with diagnosis of infection from internal joint prosthesis; encounter and management VAD
Physician orders for episode: 4/11/19-6/9/19, "Skilled Nursing (SN) orders for weekly wound measurements".
Nursing visit on 4/18/19 showed no documentation of wound measurements.

MR # 4, SOC 1/26/19; eighty-one (81) year old male with diagnosis of atherosclerosis heart disease type 2 diabetes orders for episode: 1/26/19-3/26/19, "physical therapy services 3 x/week, 4 weeks". Patient hospitalized, returned home from hospital on 2/18/19.
Physician verbal order, 2/17/19 resume PT \ services.
No order for specific therapy interventions.

Physician orders for episode: 3/27/19-5/25/19, "physical therapy services to assess/eval and treat".
No order for specific therapy interventions and/ or duration or frequency.



MR # 6, SOC 9/28/18; sixty-eight (68) year old female with diagnosis of chronic peripheral \ venous insufficiency pressure ulcer orders for episode: 3/27/19-5/25/19, "skilled nursing services 1x/wk 9 wks; 3 prn for change in condition".
Nurse provided no care week 3/10/19-3/16/19 and 3/17/19-3/23/19.
No physician notification of missed visits.


Interview with PF # 4 on 5/7/19 at approximately 2:45 PM confirmed above findings.




















Plan of Correction:

No harm to any patients regarding failure to comply with physicians' orders.
MR#2-Communication placed in patients chart 5/22/19 and faxed to physician that no weekly wound measurements obtained.
MR#4- MR #4-Order sent to physician 5/22/19 that frequency not followed for both cert periods as well as orders did not have specific therapy interventions.
MR#6-Determined no care provided 3/10-3/16/19 and 3/17/19-3/23/19 as patient hospitalized as evidenced by transfer OASIS dated 3/11/19 with resumption/recert OASIS dated 3/26/19.

All staff educated on 5/22/19 on following frequencies, writing complete detailed orders to include resumption of care orders, doing missed visit notes and faxing them to physician as well as writing orders for extra visits made, and compiling accurate medication profiles.
DON/Designee to audit 3 active charts per week for 2 weeks and then 2 active charts per week for 4 weeks. All discharged charts to be reviewed by QAPI manager. Findings of all audits to be reviewed in QAPI meeting to determine need for continued auditing of charts and continued education.


Initial Comments:


Based upon an unannounced on-site home care agency state relicensure survey conducted between 5/3/19-5/7/19, Alma Health Skilled Services LLC. 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 upon an unannounced on-site home care agency state relicensure survey conducted between 5/3/19-5/7/19, Alma Health Skilled Services LLC. was found to be in compliance with the requirements of 35 P. S.448.809 (b).





Plan of Correction: