QA Investigation Results

Pennsylvania Department of Health
BRIGHTSTAR CARE OF STROUDSBURG
Health Inspection Results
BRIGHTSTAR CARE OF STROUDSBURG
Health Inspection Results For:


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Initial Comments:

Based on the findings of an unannounced state licensure survey conducted on September 13, 2018, Brightstar Care of Stroudsburg was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health Facilities, and Subpart G. Chapter 601.




Plan of Correction:




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 on review of clinical records and interview with the administrator and the director of nursing, the agency failed to follow agency policy to ensure that the registered nurse complete a re-assessment every 60 days and failed to ensure the nurse complete a written summary report for the physician at least every 60 days. update for four (4) of four (4) clinical records. Clinical records # 1, 2, 3 and 4.
Findings include:
Review of policy of September 13, 2018 at 1500 titled " Initial Assessment and Reassessment " states " Clients receiving skilled nursing services will be reassessed every 60 days. The reassessment will be completed by a registered nurse. "
Review of policy of September 13, 2018 at 1500 titled " Plan of Care for Skilled Services " states " The physician and the home health agency review the total plan of care at least every 60 days. "
Review of clinical records revealed:
Review of clinical record # 1 on September 13, 2018 at 1030 with the certification period July 21, 2018 to September 4, 2018, did not contain documentation of a 60-day summary by the registered nurse and did not contain documentation of a re-assessment by the registered nurse.
Review of clinical record # 2 on September 13, 2018 at 1100 with the certification period July 16, 2018 to September 16, 2018, did not contain documentation of a 60-day summary by the registered nurse and did not contain documentation of a re-assessment by the registered nurse.
Review of clinical record # 3 on September 13, 2018 at 1130 with certification period August 31, 2018 to October 31, 2018, did not contain documentation of a 60-day summary by the registered nurse and did not contain documentation of a re-assessment by the registered nurse.
Review of clinical record # 4 on September 13, 2018 at 1200 with certification period June 27, 2018 to August 27, 2018, did not contain documentation of a 60-day summary by the registered nurse and did not contain documentation of a re-assessment by the registered nurse.
Interview with the administrator, owner and the director of nursing on September 13, 2018 at 1630 confirmed the above findings







Plan of Correction:

Agency will schedule a meeting with all nursing staff to instruct on documentation policies and requirements. In-service with staff is scheduled for the week of October 8, 2018.

Additionally, Agency hired a Clinical Services Manager whose primary responsibility is to manage skilled scheduling and documentation. The clinical services manager will inform nursing staff of upcoming reassessments and provide nursing staff with the required documentation for completion at each visit.

BrightStar will protect patients in similar situations by ensuring that each patient is receiving an adequate level of care, that this level of care is documented in the Plan of Treatment, and the visit notes of each discipline that provides care to the patient will correlate to the Plan of Care.

BrightStar will monitor its performance to ensure sustained compliance of clinical records with biweekly clinical record reviews, utilizing the BrightStar Chart Audit Tool. Completed tools will be kept in an appropriately labeled file.

Charts found to be out of compliance will be immediately corrected, and responsible staff will be re-educated regarding compliance with state regulations, policies and procedures to ensure patient safety and efficient clinical practice.

The Director of Nursing will be responsible for maintaining the Agency's performance and ensuring that solutions are sustained.



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 on review of clinical records and policy and procedures and interview with the administrator and the director of nursing, the facility failed to ensure that the registered nurse checked all medications to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies, and contraindicated medication and to report any problems to the physician per agency policy for eight (8) of eight (8) clinical records. Clinical record# 1, 2, 3, 4, 5, 6, 7 and 8.

Findings:

Review of policy of September 13, 2018 at 1500 titled " Identification of Medication for Administration " states " It will be the nurse ' s responsibility to be knowledge about medication to be administration including generic verses brand name clarifications, indications, normal dose range, dilution, route of delivery, rate of delivery, precautions, side effects, expected therapeutic effect, proper antidote and incompatibilities for potential interaction, relevant laboratory results, potential contraindication and side effects. "


Review of clinical record # 1 on September 13, 2018 at 1030 with the start of care on May 22, 2018, did not contain documentation that medications were reviewed to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies and contraindicated medication.

Review of clinical record # 2 on September 13, 2018 at 1100 with the start of care on May 16, 2018, did not contain documentation that medications were reviewed to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies and contraindicated medication.

Review of clinical record # 3 on September 13, 2018 at 1130 with certification period August 31, 2018 to October 31, 2018, did not contain documentation that medications were reviewed to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies and contraindicated medication.

Review of clinical record # 4 on September 13, 2018 at 1200 with certification period April 27, 2018 to June 27, 2018, did not contain documentation that medications were reviewed to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies and contraindicated medication.

Review of clinical record # 5 on September 13, 2018 at 1230 with the start of care on July 14, 2018, did not contain documentation that medications were reviewed to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies and contraindicated medication.

Review of clinical record # 6 on September 13, 2018 at 1300 with the start of care on August 23, 2018, did not contain documentation that medications were reviewed to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies and contraindicated medication.

Review of clinical record # 7 on September 13, 2018 at 1330 with the start of care on August 30, 2018, did not contain documentation that medications were reviewed to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies and contraindicated medication.

Review of clinical record # 8 on September 13, 2018 at 1400 with the start of care on December 12, 2017, did not contain documentation that medications were reviewed to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies and contraindicated medication.

Interview with the administrator, owner and the director of nursing on September 13, 2018 at 1630 confirmed that there was no documentation that medications were reviewed to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies and contraindicated medication.












Plan of Correction:

Agency Nurses will complete a medication assessment at each initial assessment and re-assessment.

Agency nurses will use the "Briggs Healthcare form 3480P" to identify medication(s) by category, classification, common side effects and provide general instructions for patient/family education needs.

BrightStar will protect patients in similar situations by ensuring that each patient is receiving an adequate level of care, that this level of care is documented in the Plan of Treatment, and that medication are reviewed with patient and family.

BrightStar will monitor its performance to ensure sustained compliance of clinical records with biweekly clinical record reviews, utilizing the BrightStar Chart Audit Tool. Completed tools will be kept in an appropriately labeled file.

Charts found to be out of compliance will be immediately corrected, and responsible staff will be re-educated regarding compliance with state regulations, policies and procedures to ensure patient safety and efficient clinical practice.

The Director of Nursing will be responsible for maintaining the Agency's performance and ensuring that solutions are sustained.




601.35(a) REQUIREMENT
SELECTION OF AIDES

Name - Component - 00
601.35(a) Selection of Aides. Home
health aides are selected on the basis
of such factors as sympathetic
attitude toward the care of the sick,
ability to read, write, and carry out
directions, and maturity and ability
to deal effectively with the demands
of the job. Aides are carefully
trained in assisting patients to
achieve maximum self-reliance,
principles of nutrition and meal
preparation, the aging process and
emotional problems of illness,
maintaining a clean, healthful, and
pleasant environment, changes in
patient's condition that should be
reported, work of the agency and the
health team, ethics and
confidentiality, and recordkeeping.

Home Health Aid Training. All home
health aides have completed a minimum
of 60 hours of classroom instruction
prior to or during the first 3 months
of employment.

They are closely supervised to assure
their competence in providing care.



Observations:



Based on the review of employee ' s files and interview with the administrator and director nursing, the agency failed to ensure that home health aide providing care to skilled care patients had a minimum of 60 class hours of instruction prior to employment or during the first three months of employment for one (1) of one (1) home health aide. Home health aide files # 1.
Findings:
Review of personnel files on September 13, 2018 from 1400 to 1500 revealed:
Home Health Aide file #1 hire date: August 26, 2018, did not contain documentation of minimum of 60 class hours of instruction.
Interview with the administrator, owner and the director of nursing on September 13, 2018 at 1630 confirmed the above findings.







Plan of Correction:

Agency will require documentation from Aides stating that 60 hours of instruction was completed, at the time of hire.

Only CNA's or Home Health Aides with the required documentation will be assigned to skilled shifts. Agency will identify certified HHAs in the computer system by adding a "tag" to their file.

BrightStar will protect patients in similar situations by ensuring that each patient is receiving an adequate level of care, that this level of care is provided by a CNA or Certified HHA.

BrightStar will monitor its performance to ensure sustained compliance of employee records with biweekly record reviews, utilizing the BrightStar Checklist Tool.

Charts found to be out of compliance will be immediately corrected, and responsible staff will be re-educated regarding compliance with state regulations, policies and procedures to ensure patient safety and efficient clinical practice.

The Director of Nursing will be responsible for maintaining the Agency's performance and ensuring that solutions are sustained.




Initial Comments:

Based on the findings of an unannounced state provisional licensure survey conducted on September 13, 2018, Brightstar Care of Stroudsburg was found to be in compliance with the requirements of 28 Pa. Code, Part IV, Health Facilities, and Subpart A. Chapter 51.




Plan of Correction:




Initial Comments:

Based on the findings of an unannounced on-site state provisional licensure survey conducted on September 13, 2018, Brightstar Care of Stroudsburg was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: