QA Investigation Results

Pennsylvania Department of Health
CLEARFIELD COMMUNITY NURSES
Health Inspection Results
CLEARFIELD COMMUNITY NURSES
Health Inspection Results For:


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Initial Comments:


Based on the findings of an on site unannounced complaint investigation survey completed 2/27/19, Clearfield Community Nurses was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.






Plan of Correction:




484.60(a)(1) STANDARD
Plan of care

Name - Component - 00
Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan.

Observations:


Based on review of clinical records (CRs) and interview with agency staff (EMP) the agency failed to provide therapy services with a individualized plan of care that identified patient-specific measurable outcomes and goals between 1/22/19 and 1/27/19 for one (1) of two (2) CRs reviewed with therapy services. (CR1).

Findings Included:

A Review of CR1 on 2/27/19 at approximately 11:15 a.m. revealed a "Home Health Referral OP" with a referral date of 1/18/19 and hand written on the front of the referral was "PT eval done 1/22/19 [listed name of therapist]". Documentation showed that a Physical Therapy referral was completed on 1/22/19 and a therapy visit by the Physical Therapy Assistant was completed on 1/24/19.

Documentation showed that CR#1 signed the "Consent for Care and Service" on 1/27/19 Additionally, the "Start of Care" initial assessment was completed by the agency Registered Nurse on 1/27/19 [nine days after the referral date and five days after the documented Physical Therapy evaluation] with a primary diagnosis of "repeated falls" and orders for "SN [skilled nurse] one visit to admit one visit to discharge and Physical Therapy 1-2 x/wk x 60 days [one to two visits per week for sixty days].

An interview with the agency administrator (EMP1) on 1/27/19 at approximately 11:30 a.m. revealed that physical therapy services are provided by contracted staff. EMP1 revealed that the contracted therapists do not do admission assessments or Oasis (a required document for patients admitted to home health services) assessments. EMP1 revealed that the consent for care form was not signed until 1/27/19 when the RN went in to complete the start of care assessment. EMP1 also confirmed that the official documented start of care date was 1/27/19 and that two therapy visits were conducted [on 1/22/19 and 1/24/19] by agency staff without a physician ordered written plan of care that identified patient-specific measurable outcomes and goals.

















Plan of Correction:

1. Communication was sent to patient's physician on 2/28/2019 notifying physician of delay in start of care, and that two Physical Therapy visits took place before the patient was admitted to services and a plan of care was developed on 1/27/2019.
2. At a staff meeting on 3/15/2019 the policy related to plan of care development was reviewed with the Clinical Manager and all staff members. Signatures were obtained form all staff members verifying they attended.
3. Communication was also sent to all contracted staff on 3/15/19 with the policy for plan of care development and COP 484.60(a)(1) attached. It was requested that all contracted staff members review the above mentioned and sign verifying they understood all requirements. Signatures will be received by 3/22/2019.
4. Immediately 100% of new admissions will be reviewed for timeliness and plan of care development by clinical supervisor, administrator or designee for two weeks 50% for one week and 10% for one week and then as need after the above is complete.
5. Results will be reviewed at monthly quality meetings for 1 month and then as needed based on further findings.





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.

Observations:



Based on a review of agency policy and procedure, clinical records (CRs), and staff interview (EMP), is was determined that the agency failed to administer therapy services only as ordered by a physician for one (1) of two (2) CRs reviewed with physician ordered therapy services. (CR1)


Findings Included:

A review of agency policy and procedure conducted on 2/27/19 at approximately 12:30 p.m. revealed: " ... Initial Assessments/Comprehensive Assessments ... Procedure ... 5. Initial Assessment and Time Frame: A RN, PT or SLP must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient's return home or on the physician-ordered start of care date. The initial assessment visit is conducted to determine the immediate care and support needs of the patient. ... ."

A Review of CR#1 on 2/27/19 at approximately 10:30 a.m. revealed a "Home Health Referral OP" with a referral date of 1/18/19 and hand written on the front of the referral was "PT eval done 1/22/19 [listed name of therapist". Documentation showed that a Physical Therapy referral was completed on 1/22/19 and an additional therapy visit by a Physical Therapy Assistant was completed on 1/24/19.

Documentation showed that CR#1 signed the "Consent for Care and Service" on 1/27/19 Additionally, the "Start of Care" initial assessment was completed by the agency Registered Nurse on 1/27/19 [nine days after the referral date and five days after the documented Physical Therapy evaluation] with a primary diagnosis of "repeated falls" and orders for "SN [skilled nurse] one visit to admit one visit to discharge and Physical Therapy 1-2 x/wk x 60 days [one to two visits per week for sixty days].

An interview with the agency administrator (EMP1) on 1/27/19 at approximately 11:30 a.m. revealed that physical therapy services are provided by contracted staff. EMP1 revealed that the contracted therapists do not do admission assessments or Oasis (a required document for patients admitted to home health services) assessments. EMP1 revealed that the consent for care form should have been signed on 1/22/19 but confirmed that it was not signed until 1/27/19 when the RN went in to complete the start of care assessment. EMP1 also confirmed that the official documented start of care date was 1/27/19 and that two therapy visits were conducted [1/22/19 and 1/24/19] by agency staff prior to this start of care date. EMP1 confirmed that those therapy visit were conducted without a physician ordered written plan of care.











Plan of Correction:

1. Communication was sent to patient's physician on 2/28/2019 notifying physician of delay in start of care, and that two Physical Therapy visits took place before the patient was admitted to services and a plan of care was developed on 1/27/2019.
2. At a staff meeting on 3/15/2019 the policies related to initial assessment, development of a plan of care, physician orders, and COP 484.60(b)(1) was reviewed with the Clinical Manager and all staff members. Signatures were obtained from all staff members verifying they attended.
3. Communication was also sent to all contracted staff on 3/15/19 with the policies for initial assessment, consent for care and services, physicians orders, and COP 484.60(b)(1) attached. It was requested that all contracted staff members review the above mentioned and sign verifying they understood all requirements. Signatures will be received by 3/22/2019.
5.Immediately 100% of active charts will be reviewed to verify compliance with all physician orders and plans of care for 2 weeks, then 50% for one week, 10% for one week then as needed once the above mentioned is complete.
6. Results will be reviewed at monthly quality meetings for 1 month and then as needed based on further findings.





484.75(b)(3) ELEMENT
Provide services in the plan of care

Name - Component - 00
Providing services that are ordered by the physician as indicated in the plan of care;

Observations:


Based on review of agency policy and clinical records (CR) and staff (EMP) interview, the skilled professional failed to provide services timely in accordance with the written orders of the physician for two (2) of two (2) CRs reviewed (CR1,CR2).

Findings Included:

A review of agency policy and procedure conducted on 2/27/19 at approximately 12:30 p.m. revealed: " ... Initial Assessments/Comprehensive Assessments ... Procedure ... 5. Initial Assessment and Time Frame: A RN, PT or SLP must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient's return home or on the physician-ordered start of care date. The initial assessment visit is conducted to determine the immediate care and support needs of the patient. ... ."

A Review of CR#1 on 2/17/19 at approximately 11:15 a.m. revealed a "Home Health Referral OP" with a referral date of 1/18/19. Documentation showed that CR#1 signed the "Consent for Care and Service" on 1/27/19 Additionally, the "Start of Care" initial assessment was completed by the agency Registered Nurse on 1/27/19 [nine days after the referral date]

An interview with the agency administrator (EMP1) on 2/27/19 at approximately 11:30 a.m. revealed that the contracted therapists do not complete admission assessments or OASIS (a required document for patients admitted to home health services) assessments. EMP1 revealed that a physical therapy evaluation was completed on 1/22/19 but the required paperwork for admission to the agency was not completed during that evaluation or during a second therapy visit made on 1/24/19. [cross-reference Tag 580] EMP1 stated that the consent for care form was not signed until 1/27/19 [nine days after referral date and five days after the physical therapy evaluation was conducted] when the RN went in to complete the start of care assessment. EMP1 confirmed the official start of care date for EMP1 was 1/27/19.

A review of CR2 conducted on 2/27/19 at approximately 11:50 a.m. revealed a "Home Health Certification And Plan of Care" with a start date of 11/19/18 and orders that included a physical therapy consult. A review of a "Coordination of Care" note dated 11/19/18 revealed "Both [listed name of therapist] P.T. and [listed name of therapist] O.T. notified by [nurse] - Today. The initial physical evaluation was not completed until 11/30/18 [eleven days after the therapist was notified of the referral]. There was no documentation within CR2 that justified the delay in treatment.

An interview with the agency administrator on 2/27/19 at approximately 11:30 a.m. confirmed the above findings with EMP1 stating "the expectation is they go in within a day or two of the consult" EMP1 also confirmed that there was no additional documentation within CR2 to justify the delay in treatment.











Plan of Correction:

1. Communication was sent to the respective physician of both patients on 2/28/2019 notifying them of the delay in initiation of care.
2. At a staff meeting 3/15/2019 the policies related to initial assessment, plan of care development and coordination of care were reviewed with all staff members. Signatures were obtained from all staff members verifying they had reviewed the information.
3. Communication was also sent to all contracted staff on 3/15/2019 with the policies for initial assessment, coordination of patient care, plan of care development, and COP 484.75(b)(3) attached. It was requested that all contracted staff members review the above and provide a signature verifying they understood all the requirements. Signatures will be obtained by 3/22/2019.
4. Immediately 100% of new admission documentation will be reviewed for timeliness of initial assessment and care plan development by clinical supervisor, administrator or designee for 2 weeks, 50% for one week and 10% for one week then as needed after the above mentioned is complete.
5. Immediately new referrals will be reviewed by administrator or designee to ensure all initial assessments are scheduled to be completed within 48 hours of receiving a complete referral. This will be completed at a rate of 100% for 2 weeks, 50% for one week, 10% for one week and as needed after the above mentioned is complete.
6. Immediately new admission documentation will be reviewed by the clinical manager, administrator or designee for evidence of coordination between therapy services, the case manager and the patient's physician of any potentially significant findings or delays in care. This will take place at a rate of 100% of new admission documentation for 2 weeks, 50% for one week, 10% for one week and as needed after the above mentioned is complete.
6. Results will be reviewed at monthly quality meetings for 1 month and then as needed based on further findings.



Initial Comments:


Based on the findings of an onsite unannounced complaint investigation survey completed 2/27/19, Clearfield Community Nurses 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 onsite unannounced complaint investigation survey completed 2/27/19, Clearfield Community Nurses was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.






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 agency policy and clinical records (CR) and staff (EMP) interview, the skilled professional failed to provide services timely in accordance with the written orders of the physician for two (2) of two (2) CRs reviewed (CR1, CR2).

Findings Included:

A review of agency policy and procedure conducted on 2/27/19 at approximately 12:30 p.m. revealed: " ... Initial Assessments/Comprehensive Assessments ... Procedure ... 5. Initial Assessment and Time Frame: A RN, PT or SLP must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient's return home or on the physician-ordered start of care date. The initial assessment visit is conducted to determine the immediate care and support needs of the patient. ... ."

A Review of CR#1 on 2/17/19 at approximately 11:15 a.m. revealed a "Home Health Referral OP" with a referral date of 1/18/19. Documentation showed that CR#1 signed the "Consent for Care and Service" on 1/27/19 Additionally, the "Start of Care" initial assessment was completed by the agency Registered Nurse on 1/27/19 [nine days after the referral date]

An interview with the agency administrator (EMP1) on 2/27/19 at approximately 11:30 a.m. revealed that the contracted therapists do not complete admission assessments or OASIS (a required document for patients admitted to home health services) assessments. EMP1 revealed that a physical therapy evaluation was completed on 1/22/19 but the required paperwork for admission to the agency was not completed during that evaluation or during a second therapy visit made on 1/24/19. EMP1 stated that the consent for care form was not signed until 1/27/19 [nine days after referral date and five days after the physical therapy evaluation was conducted] when the RN went in to complete the start of care assessment. EMP1 confirmed the official start of care date for EMP1 was 1/27/19.

A review of CR2 conducted on 2/27/19 at approximately 11:50 a.m. revealed a "Home Health Certification And Plan of Care" with a start date of 11/19/18 and orders that included a physical therapy consult. A review of a "Coordination of Care" note dated 11/19/18 revealed "Both [listed name of therapist] P.T. and [listed name of therapist] O.T. notified by [nurse] - Today." The initial physical evaluation was not completed until 11/30/18 [eleven days after the therapist was notified of the referral]. There was no documentation within CR2 that justified the delay in treatment.

An interview with the agency administrator on 2/27/19 at approximately 11:30 a.m. confirmed the above findings with EMP1 stating "the expectation is they go in within a day or two of the consult" EMP1 also confirmed that there was no additional documentation within CR2 to justify the delay in treatment.
















Plan of Correction:

1. Communication was sent to the respective physician of both patients on 2/28/2019 notifying them of the delay in initiation of care.
2. At a staff meeting 3/15/2019 the policies related to initial assessment and coordination of care was reviewed with all staff members. Signatures were obtained from all staff members verifying they had reviewed the information.
3. Communication was also sent to all contracted staff on 3/15/2019 with the policies for initial assessment, coordination of patient care and COP 601.31(b) attached. It was requested that all contracted staff members review the above and provide a signature verifying they understood all the requirements. Signatures will be obtained by 3/22/2019.
4. Immediately 100% of new admission documentation will be reviewed for timeliness of initial assessment by clinical supervisor, administrator or designee for 2 weeks, 50% for one week and 10% for one week then as needed after the above mentioned is complete.
5. Immediately new referrals will be reviewed by administrator or designee to ensure all initial assessments are scheduled to be completed within 48 hours of receiving a complete referral. This will be completed at a rate of 100% for 2 weeks, 50% for one week, 10% for one week and as needed after the above mentioned is complete.
6. Immediately new admission documentation will be reviewed by the clinical manager, administrator or designee for evidence of coordination between therapy services, the case manager and the patient's physician of any potentially significant findings or delays in care. This will take place at a rate of 100% of new admission documentation for 2 weeks, 50% for one week, 10% for one week and as needed after the above mentioned is complete.
6. Results will be reviewed at monthly quality meetings for 1 month and then as needed based on further findings.



601.33 REQUIREMENT
THERAPY SERVICES

Name - Component - 00
601.33 VI. THERAPY SERVICES.



Observations:


Based on a review of agency policy and procedure, clinical records (CRs) and interview with agency staff (EMP) the agency failed to provide therapy services with a individualized plan of care that identified patient-specific measurable outcomes and goals between 1/22/19 and 1/27/19 for one (1) of two (2) CRs reviewed with therapy services. (CR1) Additionally, the agency failed to ensure therapy services were started timely in accordance with the orders of the physician for one (1) of two (2) CRs reviewed with therapy services (CR2).

Findings Included:

A review of agency policy and procedure conducted on 2/27/19 at approximately 12:30 p.m. revealed: " ... Initial Assessments/Comprehensive Assessments ... Procedure ... 5. Initial Assessment and Time Frame: A RN, PT or SLP must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient's return home or on the physician-ordered start of care date. The initial assessment visit is conducted to determine the immediate care and support needs of the patient. ... ."

A Review of CR1 on 2/27/19 at approximately 11:15 a.m. revealed a "Home Health Referral OP" with a referral date of 1/18/19 and hand written on the front of the referral was "PT eval done 1/22/19 [listed name of therapist]". Documentation showed that a Physical Therapy referral was completed on 1/22/19 and a therapy visit by the Physical Therapy Assistant was completed on 1/24/19.

Documentation showed that CR#1 signed the "Consent for Care and Service" on 1/27/19 Additionally, the "Start of Care" initial assessment was completed by the agency Registered Nurse on 1/27/19 [nine days after the referral date and five days after the documented Physical Therapy evaluation] with a primary diagnosis of "repeated falls" and orders for "SN [skilled nurse] one visit to admit one visit to discharge and Physical Therapy 1-2 x/wk x 60 days [one to two visits per week for sixty days].

An interview with the agency administrator (EMP1) on 1/27/19 at approximately 11:30 a.m. revealed that physical therapy services are provided by contracted staff. EMP1 revealed that the contracted therapists do not do admission assessments or OASIS (a required document for patients admitted to home health services) assessments. EMP1 revealed that the consent for care form was not signed until 1/27/19 when the RN went in to complete the start of care assessment. EMP1 also confirmed that the official documented start of care date was 1/27/19 and that two therapy visits were conducted [on 1/22/19 and 1/24/19] by agency staff without a physician ordered written plan of care that identified patient-specific measurable outcomes and goals.

A review of CR2 conducted on 2/27/19 at approximately 11:50 a.m. revealed a "Home Health Certification And Plan of Care" with a start date of 11/19/18 and orders that included a physical therapy consult. A review of a "Coordination of Care" note dated 11/19/18 revealed "Both [listed name of therapist] P.T. and [listed name of therapist] O.T. notified by [nurse] - Today." The initial physical evaluation was not completed until 11/30/18 [eleven days after the therapist was notified of the referral]. There was no documentation within CR2 that justified the delay in treatment.

An interview with the agency administrator on 2/27/19 at approximately 11:30 a.m. confirmed the above findings with EMP1 stating "the expectation is they go in within a day or two of the consult" EMP1 also confirmed that there was no additional documentation within CR2 to justify the delay in treatment.










Plan of Correction:

1. Communication was sent to patient's physician on 2/28/2019 notifying physician of delay in start of care, and that two Physical Therapy visits took place before the patient was admitted to services and a plan of care was developed on 1/27/2019.
2. At a staff meeting on 3/15/2019 the policies related to initial assessment, Consent for care and services, plan of care development and COP 484.60(b)(1) was reviewed with the Clinical Manager and all staff members. Signatures were obtained form all staff members verifying they attended.
3. Communication was also sent to all contracted staff on 3/15/19 with the policies for initial assessment, consent for care and services, plan of care development and COP 601.33 attached. It was requested that all contracted staff members review the above mentioned and sign verifying they understood all requirements. Signatures will be received by 3/22/2019.
4. Immediately new admission documentation will be reviewed for timeliness of initial assessment and timeliness of completion of the consent for care and services document by clinical supervisor, administrator or designee. This will be reviewed at a rate of 100% of new admission documentation for two weeks 50% for one week, 10% for one week and then as needed after the above is complete.
5. Immediately 100% of new admission documentation will be reviewed for timely development and compliance with the plan of care plan by clinical supervisor, administrator or designee for two weeks 50% for one week and 10% for one week and then as need after the above is
6. Results will be reviewed at monthly quality meetings for 1 month and then as needed based on further findings.



Initial Comments:


Based on the findings of an onsite unannounced complaint investigation survey completed 2/27/19, Clearfield Community Nurses 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 complaint survey completed 2/27/19, Clearfield Community Nurses was found to be in compliance with the requirements of 35 P.S. 448.809 (b).






Plan of Correction: