QA Investigation Results

Pennsylvania Department of Health
CITADEL HOME CARE LLC
Health Inspection Results
CITADEL HOME CARE LLC
Health Inspection Results For:


There are  5 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 Medicare recertification survey conducted on February 12, 2018 through February 14, 2018, Skyline Home Health Care was found not to be in compliance with the requirements of 42CFR, Part 484, Subparts B & C, Conditions of Participation: Home Health Agencies.





Plan of Correction:




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 on a review of the clinical records, policies and an interview with the administrator and director of nursing, the agency failed to ensure that the plan of care had orders for care delivery that included the amount, frequency and duration of services for nine (9) of ten (10) clinical records. Clinical records 1,2,3,4,5,6,7,8 ,and 9.

Findings include:

Review of policy on February 14, 2018 at 1400 titleed " Care Plan " states " Initial assessment by a registered nurse and assessment by other disciplines, orders for services will be made from the physician. The care plan is to include a description of each service, required treatments and procedure and frequency of services. "

Review of clinical record revealed:

Clinical record # 1 reviewed on February 12, 2018 at 1100 with certification period February 1, 2018 to April 1, 2018. Plan of care dated February 1, 2018 listed goals for skilled nursing and physical therapy, no documentation of order for skilled nursing and physical therapy service to include the amount, frequency and duration of services.
Clinical record # 2 reviewed on February12, 2018 at 1230 with certification period February 1, 2018 to April 1, 2018. Plan of care dated February 1, 2018 listed goals for skilled nursing and physical, no documentation of an order for the skilled nursing and physical therapy services to include the amount, frequency and duration of services.
Clinical record # 3 reviewed on February 12, 2018 at 1315 with certification period January 5, 2018 to March 5, 2018. Plan of care dated January 5, 2018 ordered skilled nursing assessment and evaluation, physical therapy evaluation and occupational therapy evaluation. Occupational therapy evaluated on January 6, 2018 ordered occupation therapy 1 to 2 times per week for 3 to 4 weeks, no physician signature for order. Physical therapy evaluation on January 8, 2018 ordered 2 to 3 visits per week for nine weeks, no physician signature for order. No documentation of an order for skilled nursing services.
Clinical record # 4 reviewed on February 12, 2018 at 1400 with certification period December 26, 2017 to February 23, 2018. Plan of care dated December 26, 2018 orders skilled nursing assessment and evaluation, physical therapy evaluation and occupational therapy evaluation. Occupational therapy evaluated on January 11, 2018 and ordered occupation therapy 1 to 2 times per week for 4 to 5 weeks, no physician signature for order. Physical therapy evaluation on December 28, 2017 ordered physical therapy for 1 to 2 visits per week for 9 weeks, no physician signature for order. No documentation of an order for skilled nursing services.

Clinical record # 5 reviewed on February 12, 2018 at 1445 with certification period December 26, 2017 to February 23, 2018. Plan of care for December 26, 2017 ordered skilled nursing assessment and evaluation, physical therapy evaluation and occupational therapy evaluation. Physical therapy evaluation date December 28, 2017 ordered physical therapy 2 times per week, no physician signature for order and no duration on order. Occupation therapy evaluation on December 30, 2017 with order for occupational therapy 1 to 2per week for 3 weeks, no physician signature for order. No documentation of an order for skilled nursing services.
Clinical record # 6 reviewed on February 13, 2018 at 1130 with certification period January 14, 2018 to March 14, 2018, Plan of care dated January 14, 2018 ordered physical therapy evaluation and occupational therapy evaluation. There wer no physician orders for physical and occupation therapy for services delivered from January 16, 2018 to February 13, 2018.
Clinical record # 7 reviewed on February 13, 2018 at 1300 with certification period February 7, 2018 to April 7, 2018. Plan of care dated February 7, 2018 listed skilled nursing goals, no documentation of an order for the skilled nursing to include the amount, frequency and duration of services.
Clinical record # 8 reviewed on February 13, 2018 at 1400 with certification period December 3, 2016 to January 31, 2017. Plan of care dated December 3, 3017 ordered skilled nursing 3 times per week; there was no order for duration of services and no order for physical therapy evaluation. No documentation of an order for physical therapy services delivered from December 3, 2017 to January 13, 2018 three times per week.
Clinical record # 9 reviewed on February 14, 2018 at 1000 with certification period October 22, 2017 to December 20, 2017. Plan of care dated October 22, 2017 listed skilled nursing goals, no documentation of an order for the skilled nursing to include the amount, frequency and duration of services.
Interview with the administrator and director of nursing on February 14, 2018 at 1500 confirmed the above findings.













Plan of Correction:

The Director of Nursing is responsible for implementing the correction of this deficiency. While this issue is largely due to a limitation within Skyline Home Health Care's software system the following steps have been made to ensure that this is corrected moving forward.
The Director of Nursing, Assistant Director of Nursing and Administrator spoke in great length with Skyline's software vendor about the importance of our software being capable of automatically transferring the amount, frequency and duration of services from our admissions screen to the plan of care that is submitted to the referring physician for review and signature. Since an immediate fix is not possible for our software vendor, we have implemented the following correction.
All treating clinical field staff (RN, PT, OT, SLP) have been instructed that it is mandatory to include free text within the 'Treatment Goals and Orders,' screen located within the Plan of Care document. This free text must include the planned amount, frequency and duration specific to their patient. The plan of care will be submitted to the referring physician for review and signature.
All requests for continued services per discipline will be included in any recertification plan of care for physician signature. All physical, occupational and speech therapists will submit re-evaluations every 30 days to the agency to be included in the treatment plan submitted to the physician.
All clinical field staff will complete a re-certification every 60 days to continue services if deemed necessary. All re-evaluations and re-certifications will contain amount, frequency and duration of care.
If after performing a patient evaluation, it is deemed necessary or unnecessary for a specific discipline to either continue or discontinue treatment, Skyline will obtain approval of such additions or modifications to the original plan via the referring physician's sign off on verbal orders These corrections to this deficiency will be corrected no later than 3/30/2018.
Moving forward, on a weekly basis our ADON will ensure compliance with this requirement until our software vendor is able to implement a fix within our software.
Additionally, on a monthly basis the Director of Nursing will audit all plan of care(s) for submission to physicians until 100% compliance is achieved and then quarterly with documentation maintained for one year in QA meeting minutes.



484.80(g)(1) STANDARD
Home health aide assignments and duties

Name - Component - 00
Standard: Home health aide assignments and duties.
Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist).

Observations:

Based on review of clinical records, agency policy and an interview with the administrator and director of nursing, the agency failed to follow its policy to ensure that the home health aide plan of care was prepared by the registered nurse to individualize the duties to be performed by the home health aide for four (4) of four (4) clinical records with home health aide services ordered on the plan of care. Clinical records # 1, 7, 8 and 9.
Findings include:
Review of policy on February 14, 2018 at 1400 titled " Home health Aide Plan of Care " states Each patient having home health aide service is to have a care plan developed by the nurse or professional therapist at the start of care. "

Review of clinical records revealed:
Clinical record # 1 reviewed on February 12, 2018 at 1100 with certification period October 2, 2017 to December 12, 2018. Home health aide plan dated October 4, 2017 of listed a shower and a complete bed bath.
Clinical record # 7 reviewed on February 13, 2018 at 1300 with certification period February 7, 2018 to April 7, 2018. Home health aide plan dated February 7, 2018 lists complete bed bath and sponge bath up in a chair.
Clinical record # 8 reviewed on February 13, 2018 at 1400 with certification period December 3, 2016 to January 31, 2017. Home health aide plan dated December 3. 2017 lists complete bed bath and sponge bath up in a chair.
Clinical record # 9 reviewed on February 14, 2018 at 1000 with certification period October 22, 2017 to December 20, 2017. Home health aide plan dated October 22, 2017 lists shower, and complete bed bath.
Interview with the administrator and director of nursing on February 14, 2018 at 1500 confirmed that the above home health aide services were not individualized for each patient.









Plan of Correction:

The Director of Nursing is responsible for implementing the correction of this deficiency. Following survey, our Director of Nursing and Assistant Director of Nursing reviewed each home health aide plan of care for all active patients to ensure that each is individualized per patient. While a plan of care is currently created by an Registered Nurse per each client for home health aides assigned to a case, there were instances where the plan of care listed multiple activities that could appear as conflicting in nature.
The Director of Nursing and Assistant Director of Nursing contacted each client and assigned home health aide to confirm the accuracy of each plan of care. Any updates were entered accordingly. Corrections for this deficiency will be completed in full by 3/30/2018.
Moving forward any registered nurse or therapist that will create an individualized plan of care will be trained by our Assistant Director of Nursing and will be specifically instructed to ensure that activities are not conflicting and that each plan of care is tailored to the specific needs of the patient. Moreover, training will include the importance of creating free text within each plan of care to document that it is indeed individualized per patient.
The Director of Nursing will audit all plan of care(s) moving forward until 100% compliance is achieved and will continue with a quarterly audit with documentation for one year maintained in agency's QA meeting minutes.



Initial Comments:

Based on the findings of an unannounced on-site Medicare re-certification survey completed on February 23,2018, Skyline Home Health Care 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 state licensure survey conducted on February 12, 2018 through February 14, 2018, Skyline Home Health Care 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:




601.31(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:

0574

Based on a review of the clinical records, policies and an interview with the administrator and director of nursing, the agency failed to ensure that the plan of care had orders for care delivery that included the amount, frequency and duration of services for nine (9) of ten (10) clinical records. Clinical records 1,2,3,4,5,6,7,8, and 9.

Findings include:

Review of policy on February 14, 2018 at 1400 titleed " Care Plan " states " Initial assessment by a registered nurse and assessment by other disciplines, orders for services will be made from the physician. The care plan is to include a description of each service, required treatments and procedure and frequency of services. "


Clinical record # 1 reviewed on February 12, 2018 at 1100 with certification period February 1, 2018 to April 1, 2018. Plan of care dated February 1, 2018 listed goals for skilled nursing and physical therapy, no documentation of order for skilled nursing and physical therapy service to include the amount, frequency and duration of services.
Clinical record # 2 reviewed on February12, 2018 at 1230 with certification period February 1, 2018 to April 1, 2018. Plan of care dated February 1, 2018 listed goals for skilled nursing and physical, no documentation of an order for the skilled nursing and physical therapy services to include the amount, frequency and duration of services.
Clinical record # 3 reviewed on February 12, 2018 at 1315 with certification period January 5, 2018 to March 5, 2018. Plan of care dated January 5, 2018 ordered skilled nursing assessment and evaluation, physical therapy evaluation, and occupational therapy evaluation. Occupational therapy evaluated on January 6, 2018 ordered occupational therapy 1 to 2 times per week for 3 to 4 weeks, no physician signature for order. Physical therapy evaluation on January 8, 2018 ordered 2 to 3 visits per week for nine weeks, no physician signature for order. No documentation of an order for skilled nursing services.
Clinical record # 4 reviewed on February 12, 2018 at 1400 with certification period December 26, 2017 to February 23, 2018. Plan of care dated December 26, 2018 orders for skilled nursing assessment and evaluation, physical therapy evaluation, and occupational therapy evaluation. Occupational therapy evaluated on January 11, 2018 and ordered occupation therapy 1 to 2 times per week for 4 to 5 weeks, no physician signature for order. Physical therapy evaluation on December 28, 2017 ordered physical therapy for 1 to 2 visits per week for 9 weeks, no physician signature for order. No documentation of an order for skilled nursing services.

Clinical record # 5 reviewed on February 12, 2018 at 1445 with certification period December 26, 2017 to February 23, 2018. Plan of care for December 26, 2017 ordered skilled nursing assessment and evaluation, physical therapy evaluation and occupational therapy evaluation. Physical therapy evaluation date December 28, 2017 ordered physical therapy 2 times per week, no physician signature for order and no duration on order. Occupation therapy evaluation on December 30, 2017 with order for occupational therapy 1 to 2per week for 3 weeks, no physician signature for order. No documentation of an order for skilled nursing services
Clinical record # 6 reviewed on February 13, 2018 at 1130 with certification period January 14, 2018 to March 14, 2018, Plan of care dated January 14, 2018 ordered physical therapy evaluation and occupational therapy evaluation. There were no physician orders for physical and occupation therapy for services delivered from January 16, 2018 to February 13, 2018.
Clinical record # 7 reviewed on February 13, 2018 at 1300 with certification period February 7, 2018 to April 7, 2018. Plan of care dated February 7, 2018 listed skilled nursing goals, no documentation of an order for the skilled nursing to include the amount, frequency and duration of services.
Clinical record # 8 reviewed on February 13, 2018 at 1400 with certification period December 3, 2016 to January 31, 2017. Plan of care dated December 3, 3017 ordered skilled nursing 3 times per week; there was no order for duration of nursing services and no order for physical therapy evaluation. There was no documentation of a physician's order for physical therapy services delivered from December 3, 2017 to January 13, 2018 three times per week.
Clinical record # 9 reviewed on February 14, 2018 at 1000 with certification period October 22, 2017 to December 20, 2017. Plan of care dated October 22, 2017 listed skilled nursing goals, no documentation of an order for the skilled nursing to include the amount, frequency and duration of services.
Interview with the administrator and director of nursing on February 14, 2018 at 1500 confirmed the above findings.














Plan of Correction:

The Director of Nursing is responsible for implementing the correction of this deficiency. While this issue is largely due to a limitation within Skyline Home Health Care's software system the following steps have been made to ensure that this is corrected moving forward.
The Director of Nursing, Assistant Director of Nursing and Administrator spoke in great length with Skyline's software vendor about the importance of our software being capable of automatically transferring the amount, frequency and duration of services from our admissions screen to the plan of care that is submitted to the referring physician for review and signature. Since an immediate fix is not possible for our software vendor, we have implemented the following correction.
All treating clinical field staff (RN, PT, OT, SLP) have been instructed that it is mandatory to include free text within the 'Treatment Goals and Orders,' screen located within the Plan of Care document. This free text must include the planned amount, frequency and duration specific to their patient. The plan of care will be submitted to the referring physician for review and signature.
All requests for continued services per discipline will be included in any recertification plan of care for physician signature. All physical, occupational and speech therapists will submit re-evaluations every 30 days to the agency to be included in the treatment plan submitted to the physician.
All clinical field staff will complete a re-certification every 60 days to continue services if deemed necessary. All re-evaluations and re-certifications will contain amount, frequency and duration of care.
If after performing a patient evaluation, it is deemed necessary or unnecessary for a specific discipline to either continue or discontinue treatment, Skyline will obtain approval of such additions or modifications to the original plan via the referring physician's sign off on verbal orders. All corrections for this deficiency are to be implemented by no later than 3/30/2018.
Moving forward our ADON will ensure compliance on a weekly basis for this requirement until our software vendor is able to implement a fix within our software.
Additionally, the Director of Nursing will audit all plan of care(s) submitted to physicians monthly until 100% compliance is achieved and then quarterly with all documentation maintained for one year in agency's QA meeting minutes.



601.35(b) REQUIREMENT
ASSNMNT & DUTIES OF HOME HEALTH AIDE

Name - Component - 00
601.35(b) Assignment and Duties of
the Home Health Aide. The home health
aide is assigned to a particular
patient by a registered nurse. Written
instructions for patient care are
prepared by a registered nurse or
therapist as appropriate. Duties
include:
(i) the performance of simple
procedures as an extension of therapy
services,
(ii) personal care,
(iii) ambulation and exercise,
(iv) household services essential to
health care at home,
(v) assistance with medications
that are ordinarily self-administered,
(vi) reporting changes in the
patient's conditions and needs, and
(vii) completing appropriate
records.

Observations:

Based on review of clinical records, agency policy and an interview with the administrator and director of nursing, the agency failed to follow its policy to ensure that the home health aide plan of care was prepared by the registered nurse to individualize the duties to be performed by the home health aide for four (4) of four (4) clinical records with home health aide services ordered on the plan of care. Clinical records # 1, 7, 8 and 9.
Findings include:
Review of policy on February 14, 2018 at 1400 titled " Home health Aide Plan of Care " states Each patient having home health aide service is to have a care plan developed by the nurse or professional therapist at the start of care. "

Review of clinical records revealed:
Clinical record # 1 reviewed on February 12, 2018 at 1100 with certification period October 2, 2017 to December 12, 2018. Home health aide plan dated October 4, 2017 of listed a shower and a complete bed bath.
Clinical record # 7 reviewed on February 13, 2018 at 1300 with certification period February 7, 2018 to April 7, 2018. Home health aide plan dated February 7, 2018 lists complete bed bath and sponge bath up in a chair.
Clinical record # 8 reviewed on February 13, 2018 at 1400 with certification period December 3, 2016 to January 31, 2017. Home health aide plan dated December 3. 2017 lists complete bed bath and sponge bath up in a chair.
Clinical record # 9 reviewed on February 14, 2018 at 1000 with certification period October 22, 2017 to December 20, 2017. Home health aide plan dated October 22, 2017 lists shower, and complete bed bath.
Interview with the administrator and director of nursing on February 14, 2018 at 1500 confirmed that the above home health aide services were not individualized for each patient.










Plan of Correction:

The Director of Nursing is responsible for implementing the correction of this deficiency. Following survey, our Director of Nursing and Assistant Director of Nursing reviewed each home health aide plan of care for all active patients to ensure that each is individualized per patient. While a plan of care is currently created by a Registered Nurse per each client for home health aides assigned to a case, there were instances where the plan of care listed multiple activities that could appear as conflicting in nature.
The Director of Nursing and Assistant Director of Nursing contacted each client and assigned home health aide to confirm the accuracy of each plan of care. Any updates were entered accordingly. All corrections to this deficiency are to be completed no later than 3/30/2018.
Moving forward any registered nurse or therapist that will create an individualized plan of care will be trained by our Assistant Director of Nursing and will be specifically instructed to ensure that activities are not conflicting and that each plan of care is tailored to the specific needs of the patient. Moreover, training will include the importance of creating free text within each plan of care to document that it is indeed individualized per patient.
Beginning immediately, the Director of Nursing will audit all plan of care(s) monthly until 100% compliance is achieved. Then, quarterly all plan of care(s) will be audited quarterly with documentation maintained for one year in agencies QA meeting minutes.



Initial Comments:

Based on the findings of an unannounced on-site state licensure survey conducted on February 12, 2018 through February 14, 2018, Skyline Home Health Care was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health Facilities, and Subpart A. Chapter 51.



Plan of Correction:




51.3 (g)(1-14) LICENSURE
NOTIFICATION

Name - Component - 00
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.


Observations:
Based on the review of the agency's complaints and incidents and the PA Department of Health Event Reporting System and interview with the administrator and director of nursing, the agency failed to report an incident of abuse to the PA Department of Health.

Findings include:

Review of PA Department of Health Event reporting system for this agency revealed that the following event was not reported. 28 Pa. Code, Part IV, Health Facilities, and Subpart A. Chapter 51 states: "If a health care facility is aware of a situation or the occurrence of an event which could seriously compromise quality assurance or patient safety, the facility shall immediately notify the Department in writing. The notification shall include sufficient detail and information to alert the Department as to the reason for its occurrence and the steps which the health care facility shall take to rectify the situation."

Review of policy on February 14, 2018 at 1400 titled " Adverse Events/Incidents" states " Serious adverse events must be reported to the state department of health. This report should be filed within 48 hours of the serious adverse event. Events include abuse and complaints of theft "

Review of agency complaints and incidents log on February 14, 2018 at 1300 revealed that the following incidents were not reported as an event to the Department of Health:

The incident report dated September 21, 2017 stated " The client called the office to report a missing necklace. "

Interview with the administrator and the directors of nursing on February 14, 2018 at 1530 confirmed that the agency did not report the above event to the Department of Health event reporting system.




Plan of Correction:

The Administrator is responsible for implementing the correction of this deficiency. The notification regulation 51.3 was reviewed with all staff including examples of relevant instances that warrant notification to the PA Department of Health via the event reporting system. Clarification was made that an event meeting these criteria must be reported regardless of if the event has been confirmed yet by the facility.
Moving forward, all new hires are to be oriented and trained on this regulation and the types of events that warrant notification. All current employees and new hires must be trained by 3/30/2018. This topic has also been included as an agenda item on our mandatory on-site training for caregivers that is scheduled to be held at our office in April, 2018. Ongoing continuing education and training will include this topic.
Administrator is to audit monthly until 100 percent compliance is achieved and then audit quarterly with documentation for one year kept within the QA meeting minutes.



Initial Comments:

Based on the findings of an unannounced on-site state licensure survey conducted on February 12, 2018 through February 14, 2018, Skyline Home Health Care was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction:




35 P. S. 448.809b LICENSURE
Photo Id Reg

Name - Component - 00
(1) The photo identification tag shall include a recent photograph of the employee, the employee's name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.



Observations:

Based on the review of identification tags for the agency staff, the agency failed to have the title of the employee in block type and the title to occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

Findings:
When identification tags were reviewed on February 12, 2018 at 1100, it was determined that the identification tags did not contain the title of the employee in block type and the title occupying a one-half inch tall strip as close as practicable to the bottom edge of the badge.

Interview with the administrator and director of nursing on February 12, 2018 at 1200 confirmed the above findings.






Plan of Correction:

The Administrator is responsible for implementing the correction of this deficiency. All employees were notified that a new identification tag would be necessary. Administrative staff took new photographs and their identification tags now include the employee's name, the employee's title and the name of the health care facility. Employee titles are as a large as possible in block type and occupy a inch tall strip as close the bottom edge of the badge as possible.
All field staff were instructed that they need to report to the administrative office to take an updated photo. New badges that adhere to the guidelines are currently being disseminated with a completion date of 45 days, or 3/30/2018 for all employees to have compliant identification tags.
Identification tag requirements have been explained to all staff and the employee in charge of creating all new hire identification tags moving forward has the updated formal identification tag requirements.
Additionally, moving forward the Administrator will audit monthly until there is 100% compliance and then will continue quarterly with documentation for one year in facilities QA minutes.