QA Investigation Results

Pennsylvania Department of Health
EKIDZCARE
Health Inspection Results
EKIDZCARE
Health Inspection Results For:


There are  8 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 follow-up survey conducted on November 5, 2018, it was determined that the immediate jeopardy identified on October 12, 2018, at 1145, Home Health Care Agencies and 42 CFR, Part 484, Subparts B & C, Conditions of Participation: Home Health Agencies, was abated during this on-site visit. Two standard level deficiencies remain uncorrected with the addition of one new standard level deficiency.

















Plan of Correction:




484.55(a)(1) ELEMENT
RN performs assessment

Name - Component - 00
A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician- ordered start of care date.

Observations:

Based on the review of clinical records, the agency failed to have a registered nurse complete a re-assessment of the patient after hospital discharge prior to the resumption of care by the licensed practical nurse for two (2) of two (2) with hospital discharges. Clinical record # 4 and 8.
Findings include:
Review of policy on November 5, 2018 at 1400 titled "Director of Clinical Services (RN) "states "The director of clinical services is to assume responsibility and accountability for the delivery of clinical service. The director of clinical services must manage care and services according to professional standards of clinical practice, consistent with state and federal laws. "
Review of clinical record # 4 on November 5, 2018 at 1100 documented the patient's hospitalization on October 20, 2018 for hypoglycemia with a discharge on October 23, 2018 at 1030 from the hospital. The licensed practical nurse resumed care on October 23, 2018 from 2230 to 0800. Registered nurse completed resumption of care assessment on October 24, 2018 with no time recorded.
Review of clinical record # 8 on November 5, 2018 at 1400 documented the patient's hospitalization on March 15, 2018 for fever and hypoxia with a discharge on March 19, 2018. The licensed practical nurse resumed care on March 19, 2019 at 0700 to 1500. Registered nurse completed the resumption of care assessment on March 19, 2018 at 0915.
Interview with the clinical supervisor from Lancaster on November 5, 2018 at 1430 confirmed the above findings.





















Plan of Correction:

Plan of Correction:
Pertaining to tag 0514:

Per CMS Reference Manual, Tab 7, Chapter 2: Comprehensive Assessment, Q&A 15.1:
Post Hospital orders were obtained to resume services immediately upon inpatient facility discharge and resumption of care comprehensive assessment was completed within 2 calendar days; after the patient's return from inpatient facility.



484.105(a) STANDARD
Governing body

Name - Component - 00
Standard: Governing body.
A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program.

Observations:

Based on the review of agency documentation and interview with the operations manager/scheduler from Lancaster, the governing body failed to assume full legal authority and responsibility for the agency's overall management and operations, and the provision of all home health services by not having employed a registered nurse per the plan of correction for the survey dated October 12, 2018.

Findings include:
Plan of correction on October 12, 2018 states that the governing body will review the monitoring of staffing by the clinical supervisor with documentation of days and hours that they were in the office. There was no documentation by the clinical supervisors available. This surveyor was given tentative schedules of the clinical supervisors (both are registered nurses) for supervision of staff at the Allentown agency on November 5, 2018 at 1000.

The plan of correction from the survey dated October 12, 2018 stated that a registered nurse was to be hired and start on October 23, 2018. The plan also stated :"2a. Hiring of RN staff pending hire of: [ two names listed.]" On November 5, 2018 at 1000 review of the employee rooster revealed that no registered nurses have been hired.

Interview with the regional operations director conducted on November 5, 2018 at 1400 stated "The registered nurse that was to be hired and start on October 23, 2018, she worked October 23, 2108 and resigned on October 24, 2018".

On November 5, 2018 at 1000 review of the organizational chart failed to list an operations manager/scheduler.
Interview with the operations manager/scheduler from Lancaster on November 5, 2018 at 0900 stated that she is filling in due to the resignation of the operations manager/scheduler since October 17, 2018.





























Plan of Correction:

Pertaining to tag: 0942

Agency's organizational chart will be adjusted to include the title Administrator versus Director by Compliance Specialist by 11/7/18. Organizational chart will be updated to reflect Administrator change from Jennifer Woodcook, RN to Wallenstein Vidaurre. Back up Administrator will remain as Heather Tirak. Governing Body will approve of this in writing by 11/7/18.

As of 11/26/2018 Wallenstein Vidaurre removed as acting Administrator per department of health not approving of Wallenstein acting as Administrator. Wallenstein Vidaurre acting solely as the Operations Manager. Jennifer Woodcook, RN reinstated as Administrator and Heather Tirak remains as back-up Administrator. Governing body will approve of this in writing by 11/26/2018.

By 12/4/2018 the Organizational chart will be updated to reflect Administrator change from Jennifer Woodcook, RN to Tina Morgan, RN. The back-up Administrator will remain Heather Tirak. Governing Body will approve of this in writing by 12/7/2018.


On 12/4/18 Tina Morgan, RN will begin employment as the supervising RN. Ginger Townsend, RN will orient Tina Morgan, RN on-site until 12/7/18. Orientation will then continue via video, telephonic and on-site as needed. Jessica Good, RN will remain as the back-up RN, until additional RNs finalize the hiring process.

Daryl Datz, RN, Christina Land, RN, Christina Stoll, RN are currently going through the hiring process, for an external staff position. Anticipated cleared to work, with all required credentials by 12/18/18.



484.105(b)(1)(iv) ELEMENT
Ensure that HHA employs qualified personnel

Name - Component - 00
(iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies.

Observations:



Based on review of the employee register, personnel files and interview with the regional operations director, the governing body failed to follow the plan of correction from the survey of October 12, 2018 by not having hired a registered nurse.
Findings:
Plan of correction on October 12, 2018 states that the governing body will review the monitoring of staffing by the clinical supervisor with documentation of days and hours that they were in the office. There was no documentation by the clinical supervisors available. This surveyor was given tentative schedules of the clinical supervisors (both are registered nurses) for supervision of staff at the Allentown agency on November 5, 2018 at 1000. Review of staff roster on November 5, 2018 at 1030 revealed that there was no registered nurse on the staff roster.

The plan of correction for the survey conducted October 12, 2018 stated that a registered nurse was to be hired and start on October 23, 2018.
Interview with the regional operations director conducted on November 5, 2018 at 1400 stated "The registered nurse that was to be hired and start on October 23, 2018, she worked October 23, 2108 and resigned on October 26, 2018".
The operations manager/scheduler resigned on October 17, 2018. No replacement has been hired and various personnel from other office are filling in. On November 5, 2018 at 0830 the operations manager/scheduler from Lancaster was in the Allentown office.
Interview on November 5, 2018 at 1400 with the regional operations director and acting clinical manager confirmed the above findings.




















Plan of Correction:

Pertaining to tag: 0952

On 11/5/18 Ginger Townsend, RN was assigned as supervising RN and will be available during all operating business hours. Regional Clinical Director will conduct a conference with supervising RN daily to ensure transition. Meetings will then move to weekly as this is a normal reporting practice for the agency. Regional Clinical Director will report weekly to the governing body as this is a normal reporting practice for the agency.

On 12/4/18 Tina Morgan, RN will begin employment as the supervising RN. Ginger Townsend, RN will orient Tina Morgan, RN on-site until 12/21/18. Orientation will then continue via video, telephonic and on-site as needed. Jessica Good, RN will remain as the back-up RN, until additional RNs finalize the hiring process.

Daryl Datz, RN, Christina Land, RN, Christina Stoll, RN are currently going through the hiring process, for an external staff position. Anticipated cleared to work, with all required credentials by 12/18/18.



484.105(c)(1) ELEMENT
Make patient and personnel assignments,

Name - Component - 00
Making patient and personnel assignments,

Observations:

Based on the interview with the regional operations and theacting clinical manager, the agency failed to have an operations manager/scheduler to make patient and personnel assignments.
Findings include:
Interview with the regional operations manager on November 5, 2018 at 1400 when asked by this surveyor who schedules the staff for patient care and she replied that the Lancaster operations manager or a designed person in the Allentown office schedules the home health aides and licensed practical nurse. The acting clinical manger from Greensboro will schedule nursing visits. "

Plan of correction on October 12, 2018 states that the governing body will review the monitoring of staffing by the clinical supervisor with documentation of days and hours that they were in the office. There was no documentation by the clinical supervisors available. This surveyor was given tentative schedules of the clinical supervisors (both are registered nurses) for supervision of staff at the Allentown agency on November 5, 2018 at 1000. Review of staff roster on November 5, 2018 at 1030 revealed that there was no registered nurse on the staff roster.
On November 5, 2018 at 1000 review of the organizational chart failed to list an operations manager/scheduler.
The plan of correction for the survey conducted October 12, 2018 stated that a registered nurse was to be hired and start on October 23, 2018.
Interview with the regional operations director conducted on November 5, 2018 at 1400 stated "The registered nurse that was to be hired and start on October 23, 2018, she worked October 23, 2108 and resigned on October 26, 2018".
The operations manager/scheduler resigned on October 17, 2018. No replacement has been hired and various personnel from other office are filling in. On November 5, 2018 at 0830 the operations manager/scheduler from Lancaster was in the Allentown office.
















Plan of Correction:

Pertaining to tag: 0960

On 11/7/2018 the Organizational chart was updated to reflect Administrator change from Jennifer Woodcook, RN to Wallenstein Vidaurre. Back-up Administrator will remain as Heather Tirak. Governing Body approved of this in writing on 11/1/18.

As of 11/26/2018 Wallenstein Vidaurre removed as acting Administrator per department of health not approving of Wallenstein acting as Administrator. Wallenstein Vidaurre acting solely as the Operations Manager. Jennifer Woodcook, RN reinstated as Administrator and Heather Tirak remains as back-up Administrator. Governing body approved of this in writing on 11/26/2018. On 11/26/18, the Organizational chart was updated to reflect the above change.

On 10/15/18 and again on 10/18/18, a detailed clinical supervisor schedule, including hours to see patient and hours in the office, was provided via email for the month of October. Additional monthly tentative schedules was not requested. Ongoing schedules for the clinical supervisor are completed on a weekly basis and sometimes daily. All visits are documented in an Outlook calendar and can be provided upon request.

On 12/4/18 Tina Morgan, RN will begin employment as the supervising RN. Ginger Townsend, RN will orient Tina Morgan, RN on-site until 12/21/18. Orientation will then continue via video, telephonic and on-site as needed. Jessica Good, RN will remain as the back-up RN, until additional RNs finalize the hiring process.

Daryl Datz, RN, Christina Land, RN, Christina Stoll, RN are currently going through the hiring process, for an external staff position. Anticipated cleared to work, with all required credentials by 12/18/18



Initial Comments:



Based on the findings of an unannounced follow-up survey conducted on November 5, 2018, it was determined that the immediate jeopardy identified on October 12, 2018, at 1145cited under 28 Pa. Code, Part IV, Health Facilities, Subpart G. Chapter 601 was abated during this on-site visit. Two standard level deficiencies remain uncorrected with the addition of one new standard level deficiency.













Plan of Correction:




601.21(c) REQUIREMENT
GOVERNING BODY

Name - Component - 00
601.21(c) Governing Body. A governing
body (or designated persons so
functioning) assumes full legal
authority and responsibility for the
operation of the agency. The
governing body appoints: (i) a
qualified administrator, (ii) arranges
for professional service, (iii) adopts
and periodically reviews written
bylaws or an acceptable equivalent,
and (iv) oversees the management and
fiscal affairs of the agency. The
name and address of each officer,
director, and owner are disclosed to
the State agency with changes reported
promptly.



Observations:

Based on the review of agency documentation and interview with the operations manager/scheduler from Lancaster, the governing body failed to assume full legal authority and responsibility for the agency's overall management and operations, and the provision of all home health services by not having employed a registered nurse per the plan of correction for the survey dated October 12, 2018.

Findings include:
Plan of correction on October 12, 2018 states that the governing body will review the monitoring of staffing by the clinical supervisor with documentation of days and hours that they were in the office. There was no documentation by the clinical supervisors available. This surveyor was given tentative schedules of the clinical supervisors (both are registered nurses) for supervision of staff at the Allentown agency on November 5, 2018 at 1000.

The plan of correction from the survey dated October 12, 2018 stated that a registered nurse was to be hired and start on October 23, 2018. The plan of correction from the survey dated October 12, 2018 stated that a registered nurse was to be hired and start on October 23, 2018. The plan also stated :"2a. Hiring of RN staff pending hire of: [ two names listed.]" On November 5, 2018 at 1000 review of the employee rooster revealed that no registered nurses have been hired.

Interview with the regional operations director conducted on November 5, 2018 at 1400 stated "The registered nurse that was to be hired and start on October 23, 2018, she worked October 23, 2108 and resigned on October 24, 2018".

On November 5, 2018 at 1000 review of the organizational chart failed to list an operations manager/scheduler.
Interview with the operations manager/scheduler from Lancaster on November 5, 2018 at 0900 stated " She is filling in due to the resignation of the operations manager/scheduler since October 17, 2018.






























Plan of Correction:

Pertaining to tag: 1004

On 11/5/18 Ginger Townsend, RN will be assigned as supervising RN and will be available during all operating business hours. Regional Clinical Director will conduct a conference with supervising RN daily to ensure transition. Meetings will then move to weekly as this is a normal reporting practice for the agency. Regional Clinical Director will report weekly to the governing body as this is a normal reporting practice for the agency.

On 12/4/18 Tina Morgan, RN will begin employment as the supervising RN. Ginger Townsend, RN will orient Tina Morgan, RN on-site until 12/21/18. Orientation will then continue via video, telephonic and on-site as needed. Jessica Good, RN will remain as the back-up RN, until additional RNs finalize the hiring process.

Daryl Datz, RN, Christina Land, RN, Christina Stoll, RN are currently going through the hiring process, for an external staff position. Anticipated cleared to work, with all required credentials by 12/18/18


On 10/15/18 and again on 10/18/18, a detailed clinical supervisor schedule, including hours to see patient and hours in the office, was provided via email for the month of October. Additional monthly tentative schedules was not requested. Ongoing schedules for the clinical supervisor are completed on a weekly basis and sometimes daily. All visits are documented in an Outlook calendar and can be provided upon request.


On 11/7/2018 the Organizational chart was updated to reflect Administrator change from Jennifer Woodcook, RN to Wallenstein Vidaurre. Back-up Administrator will remain as Heather Tirak. Governing Body approved of this in writing on 11/1/18.

As of 11/26/2018 Wallenstein Vidaurre removed as acting Administrator per department of health not approving of Wallenstein acting as Administrator. Wallenstein Vidaurre acting solely as the Operations Manager. Jennifer Woodcook, RN reinstated as Administrator and Heather Tirak remains as back-up Administrator. Governing body approved of this in writing on 11/26/2018. On 11/26/18, the Organizational chart was updated to reflect the above change.




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 on review of the employee register, personnel files and interview with the regional operations director, the governing body failed to follow the plan of correction from the survey of October 12, 2018 by not having hired a registered nurse.
Findings:
Plan of correction on October 12, 2018 states that the governing body will review the monitoring of staffing by the clinical supervisor with documentation of days and hours that they were in the office. There was no documentation by the clinical supervisors available. This surveyor was given tentative schedules of the clinical supervisors (both are registered nurses) for supervision of staff at the Allentown agency on November 5, 2018 at 1000. Review of staff roster on November 5, 2018 at 1030 revealed that there was no registered nurse on the staff roster.

The plan of correction for the survey conducted October 12, 2018 stated that a registered nurse was to be hired and start on October 23, 2018.
Interview with the regional operations director conducted on November 5, 2018 at 1400 stated "The registered nurse that was to be hired and start on October 23, 2018, she worked October 23, 2108 and resigned on October 26, 2018".
The operations manager/scheduler resigned on October 17, 2018. No replacement has been hired and various personnel from other offices are filling in. On November 5, 2018 at 0830 the operations manager/scheduler from Lancaster was in the Allentown office.
Interview on November 5, 2018 at 1400 with the regional operations director and acting clinical manager confirmed the above findings.






























Plan of Correction:

Pertaining to tag: 1007

On 10/15/18 and again on 10/18/18, a detailed clinical supervisor schedule, including hours to see patient and hours in the office, was provided via email for the month of October. Additional monthly tentative schedules was not requested. Ongoing schedules for the clinical supervisor are completed on a weekly basis and sometimes daily. All visits are documented in an Outlook calendar and can be provided upon request.

On 12/4/18 Tina Morgan, RN will begin employment as the supervising RN. Ginger Townsend, RN will orient Tina Morgan, RN on-site until 12/21/18. Orientation will then continue via video, telephonic and on-site as needed. Jessica Good, RN will remain as the back-up RN, until additional RNs finalize the hiring process.

Daryl Datz, RN, Christina Land, RN, Christina Stoll, RN are currently going through the hiring process, for an external staff position. Anticipated cleared to work, with all required credentials by 12/18/18


On 11/7/2018 the Organizational chart was updated to reflect Administrator change from Jennifer Woodcook, RN to Wallenstein Vidaurre. Back-up Administrator will remain as Heather Tirak. Governing Body approved of this in writing on 11/1/18.

As of 11/26/2018 Wallenstein Vidaurre removed as acting Administrator per department of health not approving of Wallenstein acting as Administrator. Wallenstein Vidaurre acting solely as the Operations Manager. Jennifer Woodcook, RN reinstated as Administrator and Heather Tirak remains as back-up Administrator. Governing body approved of this in writing on 11/26/2018. Wallenstein Vidaurre job description was reinstated to Operations Manager. On 11/26/18, the Organizational chart was updated to reflect the above change.



601.32(b) REQUIREMENT
DUTIES OF THE REGISTERED NURSE

Name - Component - 00
601.32(b) Duties of the Registered
Nurse. The registered nurse:
(i) makes the initial evaluation
visit,
(ii) regularly reevaluates the
patient's nursing needs,
(iii) initiates the plan of treatment
and necessary revisions,
(iv) provides those services
requiring substantial specialized
nursing skill,
(v) initiates appropriate
preventive and rehabilitative nursing
procedures,
(vi) prepares clinical and progress
notes,
(vii) coordinates services, and
(viii) informs the physician and other
personnel of changes in the patient's
condition and needs, counsels the
patient and family in meeting nursing
and related needs, participates in
inservice programs, and supervises and
teaches other nursing personnel.

Observations:


Based on the review of clinical records, the agency failed to have a registered nurse complete a reassessment of the patient after hospital discharge prior to the resumption of care by the licensed practical nurse for two (2) of two (2) patients with hospital discharges (Clinical record # 4 and 8).
Findings:
Review of clinical record # 4 on November 5, 2018 at 1100 documented the patient's hospitalization on October 20, 2018 for hypoglycemia with a discharge on October 23, 2018 at 1030 from the hospital. The licensed practical nurse resumed care on October 23, 2018 from 2230 to 0800. Registered nurse completed resumption of care assessment on October 24, 2018 with no time recorded.
Review of clinical record # 8 on November 5, 2018 at 1400 documented the patient's hospitalization on March 15, 2018 for fever and hypoxia with a discharge of March 19, 2018. The licensed practical nurse resumed care on March 19, 2019 at 0700 to 1500. Registered nurse completed the resumption of care assessment on March 19, 2018 at 0915. The Registered nurse did not
Interview with the clinical supervisor from Lancaster on November 5, 2018 at 1430 confirmed the above findings.





Plan of Correction:

Pertaining to tag: 1023

Per CMS Reference Manual, Tab 7, Chapter 2: Comprehensive Assessment, Q&A 15.1:
Post Hospital orders were obtained to resume services immediately upon inpatient facility discharge and resumption of care comprehensive assessment was completed within 2 calendar days; after the patient's return from inpatient facility.