Initial Comments:Based on the findings of an onsite unannounced Medicare certification and state re-licensure survey completed on 3/27/24, Windber Home Health Agency was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Condition of Participation: Home Health Agencies- Emergency Preparedness.
Plan of Correction:
484.102(d)(1) STANDARD
EP Training Program
Name - Component - 00
§403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.
*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.
*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.
*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.
*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.
*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.
*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.
Observations:
Based on review of agency emergency preparedness training program, personnel files (PF) and interview with staff (EMP), the facility failed to provide initial training in emergency preparedness (EP) policies and procedures to agency staff and staff under arrangement, consistent with their expected roles in emergency preparedness training for five (5) of ten (10) PFs reviewed (PF 1, 2, 4, 9, &; 10) and ongoing training every 2 years for three (3) of six (6) PFs reviewed with employment greater than 2 years (PF 6, 9, &; 10).
Findings included:
Review of personnel files conducted March 20, 2024, at approximately 9:45am revealed:
PF1, agency staff with a date of hire 9/4/23. Evidence of emergency preparedness training dated 11/29/23.
PF2, agency staff with a date of hire 9/5/23. Evidence of emergency preparedness training dated 11/28/23.
PF4, agency staff with a date of hire 1/2/23. Evidence of emergency preparedness training dated 2/11/24.
PF6, agency staff with a date of hire 1/2/03. No evidence of emergency preparedness training every 2 years.
PF9, contracted staff with a date of hire 12/3/21. No evidence of emergency preparedness training initially or every 2 years.
PF10, contracted staff with a date of hire 12/3/21. No evidence of emergency preparedness training initially or every 2 years.
Findings confirmed at exit conference on March 26, 2024, at approximately 2:00pm with the Administrator.
Plan of Correction:Policies:
Agency implemented new policy "Emergency Preparedness Training #EDP-03" to specify the training requirements at orientation and for existing staff. The orientation plan for all new staff has been updated to included EP Training occurring within the first 30 days of hire. Additional education topics have been added to the initial training for orientation. Contract Staff have also been included in the requirement for initial and annual education.
Director
Meetings/Education:
Agency will provide education to the nursing and contracted staff on April 23, 2024. Each staff member will be provided with a copy of the policy. Staff members (agency and contracted) who were found to be delinquent on their annual education will be required to participate in additional training session offered. All materials and competency test will be completed by those staff and kept in their employee files.
Quality Improvement:
Who will monitor?
Director
What will be the sample size?
All new employees will be required to complete initial online EP training within 30 days of hire. All current employees, agency and contracted, will complete training annually and have training completed within 30 days of assignment.
Responsibility for Training
Who will complete training?
Clinical Quality Analyst, Director
How will Training be documented?
Competency Test- score of 80% or greater to pass
Corrective Action in place by:
May 15, 2024
Initial Comments:Based on the findings of an onsite unannounced Medicare certification and state re-licensure survey completed on 3/27/24, Windber Home Health Agency was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, 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 or allowed practitioner may choose to include.
Observations:
Based on review of clinical records (CR), observation of home visits (HV), review of agency policies, and interview with the administrator, it was determined that the agency failed to ensure the plan of treatment included supplies, and equipment required for seven (7) of seventeen (17) CR reviewed (CR 1, 2, 8, 10, 12, 13, &; 15).
Findings included:
Review of agency policy on 3/19/24 at approximately 2:30pm revealed:
"...Plan of Care (CM-485) Development and Coordination...PROCEDURE...The plan of care will address the following information: ...Types of services, supplies, ad equipment required. Include all DME the patient currently has in home. Include any DME the patient needs in the home. Include any medical supplies that the patient is using in the home..."
Review of CF conducted March 25, 2024, between approximately 9:15am and 1:00pm and March 26, 2024, between approximately 11:00am and 12:30pm revealed:
CR1, start of care (SOC) 7/15/23, dates reviewed 7/15/23-7/25/23. Plan of Care (POC) included orders for "compression stockings to be worn on surgical leg..." and "maintain shoulder immobilizer to affected arm." Compression stockings and shoulder immobilizer not included on POC supplies or DME.
CR2, SOC 5/12/23, dates reviewed 5/12/23-5/30/23. POC included order "to instruct patient and caregiver on the use of incentive spirometer..." Incentive spirometer not included on POC supplies or DME.
CR8, SOC 2/10/24, dates reviewed 2/10/24-3/20/24. Medication list included insulin administered based on blood glucose results. POC failed to include insulin needles.
CR10, SOC 3/5/24, dates reviewed 3/5/24-3/26/24. POC included order "to instruct patient and caregiver on the use of incentive spirometer..." Incentive spirometer not included on POC supplies or DME.
CR12, SOC 3/18/24, dates reviewed 3/18/24-3/26/24. At HV2 conducted 3/21/24 at 10:15am surveyor observed a gel cushion and patient also reported using a wheelchair. Gel cushion and wheelchair not included on POC supplies or DME.
CR13, SOC 2/28/24, dates reviewed 2/28/24-3/26/24. POC included order "to instruct patient and caregiver on the use of incentive spirometer..." Incentive spirometer not included on POC supplies or DME.
CR15, SOC 2/17/24, dates reviewed 2/17/24-3/26/24. At HV5 conducted 3/22/24 at 9:30am patient verbalized to surveyor that they [the patient] uses a c-pap at night. C-pap not included on POC supplies or DME.
Findings confirmed at exit conference on March 26, 2024, at approximately 2:00pm with the Administrator.
Repeat deficiency, previously cited: 3/18/21.
Plan of Correction:Agency has reviewed policy "Plan of Care (CM-485) Development and Coordination Policy # D-04" to ensure proper verbiage was present in policy for staff to follow in regards to documentation of medical supplies and equipment. The agency will also work with the EMR to add additional equipment and supply options into the drop-down list
Responsibility for Process:
Director
Meetings/Education:
Agency will provide education to the nursing staff on April 23, 2024. Each nurse will be provided with a copy of the policy and training on where and how to complete documentation in the EMR. Follow up regarding this process will be answered at subsequent meeting on May 14, 2024.
Quality Improvement:
Who will monitor?
Clinical Quality Analyst, Clinical Coordinator
What will be the sample size?
The agency will audit all Start of Care, Resumption of Care and Recertification charts 3 months for compliance for documentation of medical supplies and equipment. Clinicians who do not have an efficiency rate of 90% or greater will receive individual education and reinforced training on documentation. This process will continue quarterly until all clinicians are 90% or greater with compliance. The agency will also add this measure to our quarterly chart reviews for continued monitoring for compliance of all clinicians.
Responsibility for Training
Who will complete training?
Clinical Quality Analyst, Clinical Coordinator and Director
How will Training be documented?
Education Sign in Sheet
Corrective Action in place by:
May 14, 2024
484.60(b)(1) ELEMENT
Only as ordered by a physician
Name - Component - 00
Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner.
Observations:
Based on review of clinical records (CR), observation of home visits (HV), review of agency policies, and interview with the administrator, it was determined that the agency failed to provide services or treatments only as ordered by a physician for seven (7) of seventeen (17) CR reviewed (CR 1, 4, 6, 7, 15, 16, &; 17).
Findings included:
Review of agency policy on 3/19/24 at approximately 2:30pm revealed:
"...Plan of Care (CM-485) Development and Coordination...POLICY...The Home Health Certification and Plan of Care (CMS-485) will include: ...Nursing Orders and Clinical Orders: Nursing orders specify the schedule of visits... Clinical orders outline specific interventions and goals for the patient. These orders guide the care provided by clinicians., Ancillary Care Orders: ...Details the frequency and type of therapy needed..."
Review of CF conducted March 25, 2024, between approximately 9:15am and 1:00pm and March 26, 2024, between approximately 11:00am and 12:30pm revealed:
CR1, start of care (SOC) 7/15/23, dates reviewed 7/15/23-7/25/23. Plan of Care (POC) included skilled nurse (SN) frequency 2 times a week for 1 week and 1 time a week for 8 weeks starting 7/16/23. Only 1 SN visit conducted week of 7/16/23.
CR4, SOC 12/9/23, dates reviewed 12/9/23-12/28/23. POC included SN frequency 1 time a week for one week, 2 times a week for 4 weeks, and 1 time a week for 5 weeks starting 12/9/23. 3 SN visits conducted week of 12/17/23. No order for additional visit conducted.
CR6, SOC 3/5/24, dates reviewed 3/5/24-3/26/24. POC included SN frequency 2 times a week for 4 weeks and 1 time a week for 5 weeks starting 3/5/24. Additional SN visit conducted without order 3/14/24. POC included home health aide (HHA) visit frequency 1 time a week for 1 week and 2 times a week for 8 weeks starting 3/5/24. No HHA visit conducted week of 3/5/24. POC included occupational therapy (OT) visit frequency 1 time a week for 1 week and 2 times a week for 2 weeks starting 3/6/24. Only 1 OT visit conducted week of 3/10/24. CR included an order dated 3/15/24 for bloodwork to be obtained on 3/18/24. No evidence that bloodwork was obtained per order.
CR7, SOC 2/22/24, dates reviewed 2/22/24-3/26/24. POC included SN frequency 2 times a week for 4 weeks and 1 time a wee for 5 weeks starting 2/22/24. Only 1 SN visit conducted week of 3/6/24.
CR15, SOC 2/17/24, dates reviewed 2/17/24-3/26/24. POC included diagnosis of type II diabetes, parameters for blood glucose results, and blood glucose monitoring supplies. No orders for frequency of blood glucose monitoring.
CR16, SOC 2/16/24, dates reviewed 2/16/14-3/26/24. POC included orders for bloodwork to be obtained on Mondays. No evidence of bloodwork obtained Monday 3/11/24 or Monday 3/18/24. Documentation of bloodwork obtained with no corresponding orders on Saturday 3/9/24, and Wednesdays 3/13/24 and 3/20/24.
CR17, SOC 2/15/24, dates reviewed 2/15/24-3/26/24. CR included documentation of bloodwork obtained 2/29/24. No corresponding order for bloodwork.
Findings confirmed at exit conference on March 26, 2024, at approximately 2:00pm with the Administrator.
Plan of Correction:Policies:
Agency has reviewed policy "Plan of Care (CM-485) Development and Coordination Policy # D-04" to ensure proper verbiage was present in policy for staff to follow in regards to Nursing Orders and Clinical Orders. Responsibility for Process:
Director
Meetings/Education:
Agency will provide education to the nursing staff on April 23, 2024. Each nurse will be provided with a copy of the policy and training on where and how to complete documentation in the EMR for lab work and for visit frequency. Reinforcement of how to plot visits according to visit frequency as well as documentation for canceled visits and additional visits will be done. Follow up regarding this process will be answered at subsequent meeting on May 14, 2024.
Quality Improvement:
Who will monitor?
Clinical Quality Analyst, Clinical Coordinator
What will be the sample size?
The agency will audit all lab draws completed by agency for compliance on orders for lab work as well as the documentation in the EMR regarding the lab draw for three months. Clinicians who do not have an efficiency rate of 90% or greater will receive individual education and reinforced training on documentation. This process will continue quarterly until all clinicians are 90% or greater with compliance. The agency will also add this measure to our quarterly chart reviews for continued monitoring for compliance of all clinicians.
The agency will audit three random patients from each clinician's caseload weekly for three months for compliance on visit frequency orders. Clinicians who do not have an efficiency rate of 90% or greater will receive individual education and reinforced training on documentation. This process will continue quarterly until all clinicians are 90% or greater with compliance. The agency will also add this measure to our quarterly chart reviews for continued monitoring for compliance of all clinicians.
Responsibility for Training
Who will complete training?
Clinical Quality Analyst, Clinical Coordinator and Director
How will Training be documented?
Education Sign in Sheet
Corrective Action in place by:
May 14, 2024
484.75(a) STANDARD
Services by skilled professionals
Name - Component - 00
Standard: Provision of services by skilled professionals.
Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures.
Observations:
Based on review of clinical records (CR), review of agency policies, and interview with the administrator, it was determined that the agency failed to ensure wounds were assessed and managed for five (5) of seventeen (17) CR reviewed (CR 3, 4, 5, 7, &; 17).
Findings included:
Review of agency policy on 3/19/24 at approximately 2:30pm revealed:
"...Wound care Documentation...PROCEDURE...Continued/Ongoing Treatment...At each visit the patient's skin will be assessed. At each dressing change the wound will be assessed and documentation will include a description of the wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition. Include a full set of vital signs including temperature...Wound measurements are documented in the EMR to show progress to healing..."
Review of CF conducted March 25, 2024, between approximately 9:15am and 1:00pm and March 26, 2024, between approximately 11:00am and 12:30pm revealed:
CR3, start of care (SOC) 4/10/23, dates reviewed 4/10/23-4/26/23. Initial comprehensive assessment included documentation of wound to right third toe. Plan of care (POC) included corelating wound care orders. No wound assessment or measurements documented the week of 4/16/23.
CR4, SOC 12/9/23, dates reviewed 12/9/23-12/28/23. Initial comprehensive assessment included documentation of 4 wounds. Wounds #1 and #2 located on sacrococcygeal spine, #3 on left anterior thigh, and #4 to left dorsal foot. No wound measurements documented on wounds #1-#4 week of 12/10/23 or week of 12/17/23.
CR5, SOC 10/22/23, dates reviewed 10/22/23-11/12/23. Documentation of wound #1 to left foot on 10/26/23. No measurements documented week of 10/29/23 or week of 11/5/23. Documentation of wound #2 to buttock on10/31/23. No measurements documented week of 11/5/23.
CR7, SOC 2/22/24, dates reviewed 2/22/24-3/26/24. Initial comprehensive assessment included documentation of surgical wound. No measurements documented week of 3/3/24, week of 3/10/24, or week of 3/17/24.
CR17, SOC 2/15/24, dates reviewed 2/15/24-3/26/24. Initial comprehensive assessment included documentation of venous stasis ulcer to bilateral lower legs. No measurements documented week of 2/18/24, week of 2/25/24, or week of 3/17/24.
Findings confirmed at exit conference on March 26, 2024, at approximately 2:00pm with the Administrator.
Plan of Correction:Agency has updated policy "Wound Care Documentation- Policy # D-06" to include required documentation in the EMR of a comprehensive wound assessment including measurements at the start of care or upon identification of a new wound followed by a weekly comprehensive wound assessment including measurements throughout the remainder of the episode of care, or until the wound is healed.
Responsibility for Process:
Director
Meetings/Education:
Agency has provided education to the nursing staff on March 26, 2024 with follow up on April 23, 2024. Each nurse has been provided with a copy of the updated policy and training on where and how to complete documentation in the EMR.
Quality Improvement:
Who will monitor?
Clinical Quality Analyst, Clinical Coordinator
What will be the sample size?
The agency has begun auditing the charts of all wound patients and will continue for 3 months to ensure compliance on the initial SOC documentation of the comprehensive wound assessment, including measurements and will follow the process throughout the episode of care to ensure that weekly measurements are part of the weekly comprehensive wound assessment. Clinicians who do not have an efficiency rate of 90% or greater will receive individual education and reinforced training on documentation. This process will continue quarterly until all clinicians are 90% or greater with compliance. The agency will also add this measure to our quarterly chart reviews for continued monitoring for compliance of all clinicians.
Responsibility for Training
Who will complete training?
Clinical Quality Analyst, Clinical Coordinator and Director will provide training to all clinical staff including nursing and therapy clinicians.
How will Training be documented?
Education Sign in Sheet
Corrective Action in place by: May 1, 2024
Initial Comments: Based on the findings of an onsite unannounced Medicare certification and state re-licensure survey completed on 3/27/24, Windber Home Health Agency was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health, 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:
Based on review of clinical records (CR), observation of home visits (HV), review of agency policies, and interview with the administrator, it was determined that the agency failed to ensure the plan of treatment included supplies, and equipment required for seven (7) of seventeen (17) CR reviewed (CR 1, 2, 8, 10, 12, 13, &; 15).
Findings included:
Review of agency policy on 3/19/24 at approximately 2:30pm revealed:
"...Plan of Care (CM-485) Development and Coordination...PROCEDURE...The plan of care will address the following information: ...Types of services, supplies, ad equipment required. Include all DME the patient currently has in home. Include any DME the patient needs in the home. Include any medical supplies that the patient is using in the home..."
Review of CF conducted March 25, 2024, between approximately 9:15am and 1:00pm and March 26, 2024, between approximately 11:00am and 12:30pm revealed:
CR1, start of care (SOC) 7/15/23, dates reviewed 7/15/23-7/25/23. Plan of Care (POC) included orders for "compression stockings to be worn on surgical leg..." and "maintain shoulder immobilizer to affected arm." Compression stockings and shoulder immobilizer not included on POC supplies or DME.
CR2, SOC 5/12/23, dates reviewed 5/12/23-5/30/23. POC included order "to instruct patient and caregiver on the use of incentive spirometer..." Incentive spirometer not included on POC supplies or DME.
CR8, SOC 2/10/24, dates reviewed 2/10/24-3/20/24. Medication list included insulin administered based on blood glucose results. POC failed to include insulin needles.
CR10, SOC 3/5/24, dates reviewed 3/5/24-3/26/24. POC included order "to instruct patient and caregiver on the use of incentive spirometer..." Incentive spirometer not included on POC supplies or DME.
CR12, SOC 3/18/24, dates reviewed 3/18/24-3/26/24. At HV2 conducted 3/21/24 at 10:15am surveyor observed a gel cushion and patient also reported using a wheelchair. Gel cushion and wheelchair not included on POC supplies or DME.
CR13, SOC 2/28/24, dates reviewed 2/28/24-3/26/24. POC included order "to instruct patient and caregiver on the use of incentive spirometer..." Incentive spirometer not included on POC supplies or DME.
CR15, SOC 2/17/24, dates reviewed 2/17/24-3/26/24. At HV5 conducted 3/22/24 at 9:30am patient verbalized to surveyor that they [the patient] uses a c-pap at night. C-pap not included on POC supplies or DME.
Findings confirmed at exit conference on March 26, 2024, at approximately 2:00pm with the Administrator.
Repeat deficiency, previously cited: 3/18/21.
Plan of Correction:Agency has reviewed policy "Plan of Care (CM-485) Development and Coordination Policy # D-04" to ensure proper verbiage was present in policy for staff to follow in regards to documentation of medical supplies and equipment. The agency will also work with the EMR to add additional equipment and supply options into the drop-down list
Responsibility for Process:
Director
Meetings/Education:
Agency will provide education to the nursing staff on April 23, 2024. Each nurse will be provided with a copy of the policy and training on where and how to complete documentation in the EMR. Follow up regarding this process will be answered at subsequent meeting on May 14, 2024.
Quality Improvement:
Who will monitor?
Clinical Quality Analyst, Clinical Coordinator
What will be the sample size?
The agency will audit all Start of Care, Resumption of Care and Recertification charts 3 months for compliance for documentation of medical supplies and equipment. Clinicians who do not have an efficiency rate of 90% or greater will receive individual education and reinforced training on documentation. This process will continue quarterly until all clinicians are 90% or greater with compliance. The agency will also add this measure to our quarterly chart reviews for continued monitoring for compliance of all clinicians.
Responsibility for Training
Who will complete training?
Clinical Quality Analyst, Clinical Coordinator and Director
How will Training be documented?
Education Sign in Sheet
Corrective Action in place by:
May 14, 2024
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 (CR), observation of home visits (HV), review of agency policies, and interview with the administrator, it was determined that the agency failed to provide services or treatments only as ordered by a physician for seven (7) of seventeen (17) CR reviewed (CR 1, 4, 6, 7, 15, 16, &; 17).
Findings included:
Review of agency policy on 3/19/24 at approximately 2:30pm revealed:
"...Plan of Care (CM-485) Development and Coordination...POLICY...The Home Health Certification and Plan of Care (CMS-485) will include: ...Nursing Orders and Clinical Orders: Nursing orders specify the schedule of visits... Clinical orders outline specific interventions and goals for the patient. These orders guide the care provided by clinicians., Ancillary Care Orders: ...Details the frequency and type of therapy needed..."
Review of CF conducted March 25, 2024, between approximately 9:15am and 1:00pm and March 26, 2024, between approximately 11:00am and 12:30pm revealed:
CR1, start of care (SOC) 7/15/23, dates reviewed 7/15/23-7/25/23. Plan of Care (POC) included skilled nurse (SN) frequency 2 times a week for 1 week and 1 time a week for 8 weeks starting 7/16/23. Only 1 SN visit conducted week of 7/16/23.
CR4, SOC 12/9/23, dates reviewed 12/9/23-12/28/23. POC included SN frequency 1 time a week for one week, 2 times a week for 4 weeks, and 1 time a week for 5 weeks starting 12/9/23. 3 SN visits conducted week of 12/17/23. No order for additional visit conducted.
CR6, SOC 3/5/24, dates reviewed 3/5/24-3/26/24. POC included SN frequency 2 times a week for 4 weeks and 1 time a week for 5 weeks starting 3/5/24. Additional SN visit conducted without order 3/14/24. POC included home health aide (HHA) visit frequency 1 time a week for 1 week and 2 times a week for 8 weeks starting 3/5/24. No HHA visit conducted week of 3/5/24. POC included occupational therapy (OT) visit frequency 1 time a week for 1 week and 2 times a week for 2 weeks starting 3/6/24. Only 1 OT visit conducted week of 3/10/24. CR included an order dated 3/15/24 for bloodwork to be obtained on 3/18/24. No evidence that bloodwork was obtained per order.
CR7, SOC 2/22/24, dates reviewed 2/22/24-3/26/24. POC included SN frequency 2 times a week for 4 weeks and 1 time a wee for 5 weeks starting 2/22/24. Only 1 SN visit conducted week of 3/6/24.
CR15, SOC 2/17/24, dates reviewed 2/17/24-3/26/24. POC included diagnosis of type II diabetes, parameters for blood glucose results, and blood glucose monitoring supplies. No orders for frequency of blood glucose monitoring.
CR16, SOC 2/16/24, dates reviewed 2/16/14-3/26/24. POC included orders for bloodwork to be obtained on Mondays. No evidence of bloodwork obtained Monday 3/11/24 or Monday 3/18/24. Documentation of bloodwork obtained with no corresponding orders on Saturday 3/9/24, and Wednesdays 3/13/24 and 3/20/24.
CR17, SOC 2/15/24, dates reviewed 2/15/24-3/26/24. CR included documentation of bloodwork obtained 2/29/24. No corresponding order for bloodwork.
Findings confirmed at exit conference on March 26, 2024, at approximately 2:00pm with the Administrator.
Plan of Correction:Policies:
Agency has reviewed policy "Plan of Care (CM-485) Development and Coordination Policy # D-04" to ensure proper verbiage was present in policy for staff to follow in regards to Nursing Orders and Clinical Orders. Responsibility for Process:
Director
Meetings/Education:
Agency will provide education to the nursing staff on April 23, 2024. Each nurse will be provided with a copy of the policy and training on where and how to complete documentation in the EMR for lab work and for visit frequency. Reinforcement of how to plot visits according to visit frequency as well as documentation for canceled visits and additional visits will be done. Follow up regarding this process will be answered at subsequent meeting on May 14, 2024.
Quality Improvement:
Who will monitor?
Clinical Quality Analyst, Clinical Coordinator
What will be the sample size?
The agency will audit all lab draws completed by agency for compliance on orders for lab work as well as the documentation in the EMR regarding the lab draw for three months. Clinicians who do not have an efficiency rate of 90% or greater will receive individual education and reinforced training on documentation. This process will continue quarterly until all clinicians are 90% or greater with compliance. The agency will also add this measure to our quarterly chart reviews for continued monitoring for compliance of all clinicians.
The agency will audit three random patients from each clinician's caseload weekly for three months for compliance on visit frequency orders. Clinicians who do not have an efficiency rate of 90% or greater will receive individual education and reinforced training on documentation. This process will continue quarterly until all clinicians are 90% or greater with compliance. The agency will also add this measure to our quarterly chart reviews for continued monitoring for compliance of all clinicians.
Responsibility for Training
Who will complete training?
Clinical Quality Analyst, Clinical Coordinator and Director
How will Training be documented?
Education Sign in Sheet
Corrective Action in place by:
May 14, 2024
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 review of clinical records (CR), review of agency policies, and interview with the administrator, it was determined that the agency failed to ensure wounds were assessed and managed for five (5) of seventeen (17) CR reviewed (CR 3, 4, 5, 7, &; 17).
Findings included:
Review of agency policy on 3/19/24 at approximately 2:30pm revealed:
"...Wound care Documentation...PROCEDURE...Continued/Ongoing Treatment...At each visit the patient's skin will be assessed. At each dressing change the wound will be assessed and documentation will include a description of the wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition. Include a full set of vital signs including temperature...Wound measurements are documented in the EMR to show progress to healing..."
Review of CF conducted March 25, 2024, between approximately 9:15am and 1:00pm and March 26, 2024, between approximately 11:00am and 12:30pm revealed:
CR3, start of care (SOC) 4/10/23, dates reviewed 4/10/23-4/26/23. Initial comprehensive assessment included documentation of wound to right third toe. Plan of care (POC) included corelating wound care orders. No wound assessment or measurements documented the week of 4/16/23.
CR4, SOC 12/9/23, dates reviewed 12/9/23-12/28/23. Initial comprehensive assessment included documentation of 4 wounds. Wounds #1 and #2 located on sacrococcygeal spine, #3 on left anterior thigh, and #4 to left dorsal foot. No wound measurements documented on wounds #1-#4 week of 12/10/23 or week of 12/17/23.
CR5, SOC 10/22/23, dates reviewed 10/22/23-11/12/23. Documentation of wound #1 to left foot on 10/26/23. No measurements documented week of 10/29/23 or week of 11/5/23. Documentation of wound #2 to buttock on10/31/23. No measurements documented week of 11/5/23.
CR7, SOC 2/22/24, dates reviewed 2/22/24-3/26/24. Initial comprehensive assessment included documentation of surgical wound. No measurements documented week of 3/3/24, week of 3/10/24, or week of 3/17/24.
CR17, SOC 2/15/24, dates reviewed 2/15/24-3/26/24. Initial comprehensive assessment included documentation of venous stasis ulcer to bilateral lower legs. No measurements documented week of 2/18/24, week of 2/25/24, or week of 3/17/24.
Findings confirmed at exit conference on March 26, 2024, at approximately 2:00pm with the Administrator.
Plan of Correction:Agency has updated policy "Wound Care Documentation- Policy # D-06" to include required documentation in the EMR of a comprehensive wound assessment including measurements at the start of care or upon identification of a new wound followed by a weekly comprehensive wound assessment including measurements throughout the remainder of the episode of care, or until the wound is healed.
Responsibility for Process:
Director
Meetings/Education:
Agency has provided education to the nursing staff on March 26, 2024 with follow up on April 23, 2024. Each nurse has been provided with a copy of the updated policy and training on where and how to complete documentation in the EMR.
Quality Improvement:
Who will monitor?
Clinical Quality Analyst, Clinical Coordinator
What will be the sample size?
The agency has begun auditing the charts of all wound patients and will continue for 3 months to ensure compliance on the initial SOC documentation of the comprehensive wound assessment, including measurements and will follow the process throughout the episode of care to ensure that weekly measurements are part of the weekly comprehensive wound assessment. Clinicians who do not have an efficiency rate of 90% or greater will receive individual education and reinforced training on documentation. This process will continue quarterly until all clinicians are 90% or greater with compliance. The agency will also add this measure to our quarterly chart reviews for continued monitoring for compliance of all clinicians.
Responsibility for Training
Who will complete training?
Clinical Quality Analyst, Clinical Coordinator and Director will provide training to all clinical staff including nursing and therapy clinicians.
How will Training be documented?
Education Sign in Sheet
Corrective Action in place by: May 1, 2024
Initial Comments:Based on the findings of an onsite unannounced Medicare certification and state re-licensure survey completed on 3/27/24, Windber Home Health Agency was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:Based on the findings of an onsite unannounced Medicare certification and state re-licensure survey completed on 3/27/24, Windber Home Health Agency was found to be in compliance with the requirements of 35 P.S.§ 448.809 b.
Plan of Correction:
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