QA Investigation Results

Pennsylvania Department of Health
ACROSS THE LIFESPAN HOME CARE INC.
Health Inspection Results
ACROSS THE LIFESPAN HOME CARE INC.
Health Inspection Results For:

This is the only survey for this facility

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 state re-licensure survey conducted on 2/5/19, Across The Lifespan Home Care Inc., was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health facilities, Subpart G. Chapter 601.








Plan of Correction:




601.22(a) REQUIREMENT
ANNUAL POLICY REVIEW

Name - Component - 00
601.22(a) Annual Policy Review. A
group of professional personnel, which
includes at least one practicing
physician and one registered nurse,
and with appropriate representation
from other professional disciplines,
establishes and annually reviews the
agency's policies governing scope of
services offered, admission and
discharge policies, medical
supervision and plans of treatment,
emergency scope of services offered,
medical care, clinical records,
personnel qualifications, and program
evaluation.

Observations:


Based on review of agency documentation, review of policy and procedure , Governing Body meeting minutes and interview with the Assistant Administrator, it was determined the agency failed to ensure the Governing Body annually reviewed the agency's policies.

Findings include:

1. A review of policy and procedure titled, "Governing Body" on 2/5/19 at approximately 12:10 PM revealed, "Governing Body is the governing authority of the Agency, and has full legal authority and responsibility for its operation... and at least annually reviews and adopts the Agency's By-laws, personnel policies and patient/client care policies and procedures...".

2. A review of the Governing Body's meeting minutes dated 3-19-18, on 2-5-19, revealed there was no documentation to show the policies and procedures were reviewed at this meeting.

3. An interview with the Assistant Administrator was conducted on 2/5/19,at approximately 12:15 PM. The Assistant Administrator confirmed the above finding.



















Plan of Correction:

The Administrator will oversee the Director of Nursing to assure the Governing Body review the Agency's By-Laws, personnel policies and patient/client care policies will be reviewed annually with meeting minutes documented and kept within the agency.


601.22(b) REQUIREMENT
ADVISORY AND EVALUATION FUNCTION

Name - Component - 00
601.22(b) Advisory and Evaluation
Function. The group of professional
personnel meets at least annually to
advise the agency on professional
issues, participate in the evaluation
of the agency's program and assist the
agency in maintaining liason with
other health care providers in the
community information program. Its
meetings are documented by dated
minutes. Note dates of last two
meetings.

Observations:


Based on a review of Agency documentation, Agency Policy, and interview with the Assistant Administrator, it was determined, that the Agency failed to follow its policy that an Professional Advisory Meeting would take place annually.
1. A review of the policy entitled, "Professional Advisory Committee " on 2-5-19 approximately 12:10 PM revealed, " The Agency utilizes a group of professional personnel to oversee and evaluate Agency operations. . . This committee meets at least annually to review policies and procedures...".

2. No minutes of a Professional Advisory Committee was available at the time of the survey for 2018.

3. An interview was conducted with Assistant Administrator on 2/5/19 at approximately 1:00 PM. The Assistant Administrator confirmed to the surveyor no Professional advisory meeting took place this year, "Due to not having any patients for 2018".







Plan of Correction:

The Administrator will oversee the Director of Nursing to assure a Professional Advisory Meeting will take place annually with minutes documented and kept in the agency.


601.22(c) REQUIREMENT
ANNUAL PROGRAM EVALUATION

Name - Component - 00
601.22(c) Annual Program Evaluation.
The home health agency has written
policies requiring an overall
evaluation of the agency's total
program at least once a year by: (i)
the group of professional personnel
(or a committee of this group), agency
staff and consumers, or by (ii)
professional people outside the agency
working in conjunction with consumers.

The evaluation consists of an overall
policy and administrative review and a
clinical record review. The
evaluation assesses the extent to
which the agency's program is
appropriate, adequate, effective and
efficient. Results of the evaluation
are reported to and acted upon by
those responsible for the operation of
the agency and are maintained
separately as administrative records.

As a part of the evaluation process
the policies and administrative
practices of the agency are reviewed
to determine the extent to which they
promote patient care that is
appropriate, adequate, effective, and
efficient. Mechanisms are established
in writing for the collection of
pertinent data to assist in
evaluation. The data to be considered
may include but are not limited to:
number of patients receiving each
service offered, number of patient
visits, reasons for discharge,
breakdown by diagnosis, sources of
referral, number of patients not
accepted, with reasons, and total
staff days for each service offered.


Observations:


Based on review of agency documentation, interview with Assistant Administrator and review of policy and procedure, it was determined the agency failed to follow agency policy requiring an overall evaluation of the agency's total program at least once a year by the group of professional personnel.

Findings include:

1. Review of policy 1.008.1 titled, "Annual Evaluation" on 2-5-19 approximately 12:00 PM states, " . . . Advisory Committee . . 1. The Agency utilizes a group of professional personnel to oversee and evaluate Agency operations. . . This committee meets at least twice yearly to review policies and procedures, to assist with the development and implementation of a community awareness program, to evaluate the Agency's total program, and to review and approve minutes of committee meetings. . ."

2. Review of the Governing Body Meeting Minutes, dated 03/18/18 on 02/05/19 at approximately 12:15 PM revealed there was no documentation of an annual program evaluation done for the year 2018.

3. Interview with Assistant Administrator on at approximately 1:00 PM confirmed the evaluation wasn't done.










Plan of Correction:

The Administrator will oversee the Director of Nursing to assure the Agency's Annual Evaluation will be completed and meeting minutes will be documented and kept within the Agency.


Initial Comments:


Based on the findings of an unannounced on-site licensure conducted on 2/5/19, Across The Lifespan Home Care Inc., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).











Plan of Correction:




Initial Comments:


Based on the findings of an unannounced on-site licensure survey conducted on 2/5/19, Across The Lifespan Home 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: