QA Investigation Results

Pennsylvania Department of Health
AROUND-THE-CLOCK NURSING, INC.
Health Inspection Results
AROUND-THE-CLOCK NURSING, INC.
Health Inspection Results For:


There are  8 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:

Based on the findings of an onsite unannounced Medicare recertification survey conducted on March 11, 2019 through March 13, 2019, Around-The-Clock Nursing was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Part 484, Subparts B & C, Conditions of Participation: Home Health Agencies.







Plan of Correction:




484.45(a) STANDARD
Encoding and transmitting OASIS

Name - Component - 00
Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary.

Observations:


Based on a review of validation reports, agency policy, and interview with the administrator and the clinical manger, the agency failed to follow its policy regarding transmitting OASIS (Outcome Assessment Information Set) for nine (9) of eleven (11) clinical records receiving skilled services over the age of eighteen per agency policy. Clinical records # 3, 4, 5, 6, 7, 8, 9, 10 and 11.

Findings:
Review of Casper reports on March 8, 2919 at 1530 revealed that the agency had not submitted Oasis from September 2018 to February 2019.
When asked for validation reports on March 13, 2019 at 1500, the director of nursing stated, " The oasis data sets are on my computer and she did not know how to find the validation reports. "
There were no validation reports to review.
Review of policy on March 13, 2019 at 1430 titled " Oasis" states " The Oasis tool will be used on patients over the age of 18 who are receiving skilled nursing care. HHAs are required to encode and electronically submit data to CMS within 30 days of the date the assessment was completed "
Review of clinical record of patients over the age of 18 revealed:
Review of clinical record # 3 on March 11, 2019 at 1100 with certification period February 21, 2019 to April 21, 2019, no documentation of oasis transmission.
Review of clinical record #4 on March 11, 2019 at 1330 with certification period February 1, 2019 to April 1, 2019, no documentation of oasis transmission.
Review of clinical record # 5 on March 11, 2019 at 1200 with certification period March 1, 2019 to April 29, 2019, no documentation of oasis transmission.
Review of clinical record # 6 on March 11, 2019 at 1230 with certification period January 5, 2019 to March 5, 2019, no documentation of oasis transmission.
Review of clinical record # 7 on March 11, 2019 at 1300 with certification period January 18, 2019 to March 18, 2019, no documentation of oasis transmission.
Review of clinical record # 8 on March 19, 2019 at 1430 with certification period May 19, 2018 to July 19, 2018, no documentation of oasis transmission.
Review of clinical record # 9 on March 19, 2019 at 1500 with certification period March 12, 2018 to May 10, 2018, no documentation of oasis transmission.
Review of clinical record # 10 on March 20, 2019 at 1000 with certification period February 1, 2019 to April 1, 2019, no documentation of oasis transmission.
Review of clinical record # 11 on March20, 2018 at 0930 with certification period JANUARY 9, 2019 TO March 9, 2019, no documentation of oasis transmission.
Interview with the administrator and the director of nursing on March 13, 2019 at 3 PM revealed that the comprehensive assessment and the oasis are done and entered into Haven but were not transferred to CMSNet access requirements, all OASIS assessment are transmitted directly to CMS via the .

Interview with the administrator and director of nursing on March 13, 2019 at 1530 confirmed the above findings.







Plan of Correction:

After review of the findings Around The Clock Nursing has reached out to the CMS secure portal to obtain assistance with the QARM system in which to transfer OASIS documents securely through the QTSO website. Submission of OASIS data will be completed on May 10, 2019 and thereafter on the first Tuesday of every month and will be tracked on the OASIS Assessment Form. A Casper report documenting all OASIS submissions will be placed in the OASIS binder in order to accurately track submission with validation reviewed after each OASIS submission. A QI recording will be instituted and followed through on a quarterly basis during the Clinical Record Review.


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 a review of personnel files and interview with the administrator, the agency failed to conduct screening for mycobacterium tuberculosis in accordance with Centers for Disease Guidelines for three (3) of fourteen (14) personnel files per agency ' s policies. Personnel files # 1, 2 and 3.

Findings include:

Review of the CDC (Centers for Disease Control) guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. HCWs with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease.
CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005 ;( RR-17)
.

Review of policy on March 22, 2019 at 3 pm titled "Tuberculin Skin Testing" states " All new employees must produce a negative TB screening at the time of employment or a negative chest x-ray. TB negative results are good for one year."

Review of personnel files on March 13, 2019 from 12:15 to 12:45 revealed:
Personnel file # 1 with date of hire on February 20, 2009. No documentation of annual tuberculin (TST) skin test for calendar year 2018.
Personnel file # 2 with date of hire on April 5, 2017. No documentation of annual tuberculin (TST) skin test for calendar year 2018.
Personnel file # 3 with date of hire on August 24, 2017. No documentation of annual tuberculin (TST) skin test for calendar year 2018.
Interview with the administrator on March 13, 2019 at 4 PM confirmed the above findings.












Plan of Correction:

Around The Clock Nursing's policy was changed to include TB Assessment screening. This policy will be reviewed by the Governing Body on May 10, 2019.
This information will then be shared with the Professional Advisory Committee. TB Screening will be monitored during clinical record review to evaluate policy change until there is a 100% accuracy is noted for 6 consecutive months.


Initial Comments:

Based on the findings of an onsite unannounced Medicare recertification survey conducted on March 11, 2019 through March 13, 2019, Around-The-Clock Nursing was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.








Plan of Correction:




484.102(a)(1)-(2) STANDARD
Plan Based on All Hazards Risk Assessment

Name - Component - 00
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

*[For LTC facilities at 483.73(a)(1):] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.

*[For ICF/IIDs at 483.475(a)(1):] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at 418.113(a)(2):] (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

Observations:

Based on a review of facility policies/procedures, documentation, and interview with the administrator and director of nursing, the agency failed to ensure the emergency preparedness plan included a completed "Hazard Vulnerability Assessment".

Findings include:

Review of agency Emergency Preparedness on March 13, 2019 at 1300, no documentation of "Hazard Vulnerability Assessment".

During interview on March 13, 2019 at 1530, the administrator and the clinical director confirmed that the agency had failed to complete a "Hazard Vulnerability Assessment".








Plan of Correction:

The Hazard Vulnerability Analysis and Assessment will be completed on May 10, 2019.

SUBJECT: HAZARD VULNERABILITY ANALYSIS


Policy: Around The Clock Nursing Inc. will perform a Hazard Vulnerability Analysis yearly which will then be used to develop any changes to the Emergency Preparedness Program.


Practice/Procedure/Implementation:

1. Hazard Vulnerability Assessment will be completed by the administrator or designee annually.

2. List potential Hazardous events for specific locations.

3. Evaluate each event for probability, vulnerability, and preparedness.

4. Probability, vulnerability, and preparedness are rated on a three level scale from high to low. Probability and vulnerability are ranked with a score of "3" for high, "2" for moderate and "1" for low. Conversely, for the preparedness category, score of "3" represents a low ranking for preparedness while a score of "1" represents a high level of preparedness. A score of "2" represents a moderate ranking for preparedness.

5. When evaluating probability, consider the frequency and likelihood an event may occur.

6. When evaluating vulnerability, consider the degree with which the organization will be impacted, such as, infrastructure damage, loss of life, service disruption, ect.
.
7. When evaluating preparedness, consider elements, such as, the strength of your preparedness plans and the organization's previous experience with the hazardous event. Multiply the ratings for each event in the area of probability, vulnerability, and preparedness. The total values with the higher scores will represents the events most in need of organization planning for emergency preparedness. Using this method, 1 is the lowest possible score while 27 is the highest possible score.

8. Strategies for each risk identified are located on the Hazard Event Management Plan.




(Devised 4/15/2019)



SUBJECT: HAZARD VULNERABILITY ASSESSMENT



Policy: Around The Clock Nursing will complete a Hazard Vulnerability Assessment yearly to provide information for the vulnerability analysis.


Practice/Procedure/Implementation:
1. Around The Clock Nursing will modify the sample Hazard Vulnerability Assessment Form. It will be modified in order to quantify the risks that clients and staff face in the geographical locations covered by Around The Clock Nursing.

2. The Hazard Vulnerability Assessment will be completed at the beginning of each year. The Assessment will be expanded into an analytic document to show both strength and weaknesses of the geographical area that Around The Clock Nursing covers.


3. The information will be shared with the Governing Body and the Professional Advisory Committee during the first meeting of each year.

4. Recommendations from both parties will assist in providing structure of the Emergency Preparedness for the counties that Around The Clock Nursing serves.













(Devised 4/15/2019)
AROUND THE CLOCK NURSING


HAZARD VULNERABILITY ASSESSMENT




EVENT PROBABILITY LEVEL OF VULNERABILITY DEGREE OF DISRUPTION PREPAREDNESS SCORE
High Moderate Low High Moderate Low High Moderate Low

Hurricane
Tornadoes
Heavy Thunder Storms
Flash Flooding
Flooding
High Winds
Severe Winter Weather (Snow/Ice)
Extreme High Heat
Drought
Wildfire
Earthquake
War
Toxic Material Spill
Riot/Civil Disorder
Nuclear Disaster
Terrorism
Electrical
Communications
IT System
Heating/Cooling
Disease Outbreak
Utility Failure
Transportation Failure
DME Interruption
TOTAL


DATE ______________________




484.102(a)(4) STANDARD
Local, State, Tribal Collaboration Process

Name - Component - 00
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:]

(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.

* [For ESRD facilities only at 494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the dialysis facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.

Observations:

Based on interview with the administrator and director of nursing and the review of agency documentation and the agency ' s emergency preparedness plan, the agency failed to have included a process for cooperation and collaboration with local, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency.

Findings:
Review of agency licensure application on March 8, 2019 at 1530 revealed that the agency provides services to patients in Berks, Bucks, Carbon, Lehigh, Monroe, Northampton and Schuylkill counties.
Review of emergency preparedness plan on March 13, 2019 at 1300, no documentation of process of collaboration with local emergency management officials, regional, State, and Federal emergency preparedness officials.
Interview with the administrator and regional operations manager on March 13, 2019 at 1500 confirmed the above findings.






Plan of Correction:

Around The Clock Nursing will revise their Emergency Disaster Plan to include the collaboration and cooperation with the local, regional, state and federal emergency preparedness officials. A listing of all emergency groups with their contact information for each county will be devised and kept by the Administrator, Director of Nursing, and Office Manager. Information will be given to all clients and staff currently employed by May 10, 2019. The information will be placed in orientation process and yearly in-service education.

EMERGENCY DISASTER PREPAREDNESS PLAN



Definition: Emergency disaster preparedness shall be interpreted as a sudden need for" immediate action which includes the implementation of procedures to assure that health care and safety needs of the patient continue to be met during emergencies" which interfere with the delivery of services. An Annual Vulnerability and Analysis will be conducted within the first quarter of every year. The findings of the analysis will direct the local, state and Federal departments.

Triage Plan for Inclement Weather:

An alternate site will be chosen for all office staff to communicate from in the
event of a severe weather situation. At the discretion of the administration,
individual triage centers may be established as needed.


Policy: All employees will be oriented to the Emergency Disaster Preparedness Plan, along with their responsibilities in carrying out the plan, upon hire and annually in serviced on the current agency plan. Patient rosters will be prioritized by need on an ongoing basis, designated by diagnosis, care and/or treatment, plan, support systems in place, special equipment needs and safety needs.

Around The Clock Nursing will have contacts for all local and regional emergency management groups to devise emergency contingencies. The agency will partake in local, regional or state emergency preparedness test. The agency will also maintain a list of all local/regional emergency preparedness contact numbers.


LEVEL I -Patients that cannot be left alone or have special equipment needs, such as ventilators.

LEVEL 2-Patients that can be left alone for short periods of time.

LEVEL 3-Patients that can be left alone, or have significant others or support systems in place.

Top priority (LEVEL 1) patients will be flagged with an asterisk. Prioritization will be done by the Director of Nursing or the supervising nurse. The Director of Nursing, or designee, will determine the point of initiation of emergency response measures. Staff members, as appropriate to the extent and nature of the emergency, will be notified.
In the event of an emergency, staffing will be reprioritized and scheduling done by the Director of Nursing or the supervising nurse on a patient priority basis. The supervising nurse or designee will attempt to contact.









































(Revised 4/16/2019)





Initial Comments:

Based on the findings of an unannounced on-site state licensure survey conducted on March 11, 2019 through March 13, 2019, Around-The-Clock Nursing was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health Facilities, and Subpart G. Chapter 601.




Plan of Correction:




601.3 REQUIREMENT
COMPLIANCE W/ FED, ST, & LOCAL LAWS

Name - Component - 00
601.3 COMPLIANCE WITH FEDERAL,
STATE AND LOCAL LAWS.
The home health agency and its staff
are in compliance with all applicable
Federal, State and Local Laws and
regulations.

Observations:


Based on a review of validation reports, agency policy, and interview with the administrator and the clinical manger, the agency failed to follow its policy regarding transmitting OASIS (Outcome Assessment Information Set) for nine (9) of eleven (11) clinical records receiving skilled services over the age of eighteen per agency policy. Clinical records # 3, 4, 5, 6, 7, 8, 9, 10 and 11.

Findings:

According to 484.45(a) Encoding and Transmitting OASIS data: "Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary."

Review of Casper reports on March 8, 2919 at 1530 revealed that the agency had not submitted Oasis from September 2018 to February 2019.
When asked for validation reports on March 13, 2019 at 1500, the director of nursing stated, " The oasis data sets are on my computer and she did not know how to find the validation reports. "
There were no validation reports to review.
Review of policy on March 13, 2019 at 1430 titled " Oasis" states " The Oasis tool will be used on patients over the age of 18 who are receiving skilled nursing care. HHAs are required to encode and electronically submit data to CMS within 30 days of the date the assessment was completed "
Review of clinical record of patients over the age of 18 revealed:
Review of clinical record # 3 on March 11, 2019 at 1100 with certification period February 21, 2019 to April 21, 2019, no documentation of oasis transmission.
Review of clinical record #4 on March 11, 2019 at 1330 with certification period February 1, 2019 to April 1, 2019, no documentation of oasis transmission.
Review of clinical record # 5 on March 11, 2019 at 1200 with certification period March 1, 2019 to April 29, 2019, no documentation of oasis transmission.
Review of clinical record # 6 on March 11, 2019 at 1230 with certification period January 5, 2019 to March 5, 2019, no documentation of oasis transmission.
Review of clinical record # 7 on March 11, 2019 at 1300 with certification period January 18, 2019 to March 18, 2019, no documentation of oasis transmission.
Review of clinical record # 8 on March 19, 2019 at 1430 with certification period May 19, 2018 to July 19, 2018, no documentation of oasis transmission.
Review of clinical record # 9 on March 19, 2019 at 1500 with certification period March 12, 2018 to May 10, 2018, no documentation of oasis transmission.
Review of clinical record # 10 on March 20, 2019 at 1000 with certification period February 1, 2019 to April 1, 2019, no documentation of oasis transmission.
Review of clinical record # 11 on March20, 2018 at 0930 with certification period JANUARY 9, 2019 TO March 9, 2019, no documentation of oasis transmission.
Interview with the administrator and the director of nursing on March 13, 2019 at 3 PM revealed that the comprehensive assessment and the oasis are done and entered into Haven but were not transferred to CMSNet access requirements, all OASIS assessment are transmitted directly to CMS via the .

Interview with the administrator and director of nursing on March 13, 2019 at 1530 confirmed the above findings.









Plan of Correction:

After review of the findings Around The Clock Nursing has reached out to the CMS secure portal to obtain assistance with the QARM system in which to transfer OASIS documents securely through the QTSO website. Submission of OASIS data will be completed on May 10, 2019 and the first Tuesday of every month. We will review OASIS validation after each submission, and will be tracked on the OASIS Assessment Form. A Casper report documenting all OASIS submissions will be placed in the OASIS binder in order to accurately track submission. A QI recording will be instituted and followed through on a quarterly basis during the Clinical Record Review.


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 a review of personnel files and interview with the administrator, the agency failed to conduct screening for mycobacterium tuberculosis in accordance with Centers for Disease Guidelines for three (3) of fourteen (14) personnel files per agency ' s policies. Personnel files # 1, 2 and 3.

Findings include:

Review of the CDC (Centers for Disease Control) guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. HCWs with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease.
CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005 ;( RR-17)
.

Review of policy on March 22, 2019 at 3 pm titled "Tuberculin Skin Testing" states " All new employees must produce a negative TB screening at the time of employment or a negative chest x-ray. TB negative results are good for one year."

Review of personnel files on March 13, 2019 from 12:15 to 12:45 revealed:
Personnel file # 1 with date of hire on February 20, 2009. No documentation of annual tuberculin (TST) skin test for calendar year 2018.
Personnel file # 2 with date of hire on April 5, 2017. No documentation of annual tuberculin (TST) skin test for calendar year 2018.
Personnel file # 3 with date of hire on August 24, 2017. No documentation of annual tuberculin (TST) skin test for calendar year 2018.
Interview with the administrator on March 13, 2019 at 4 PM confirmed the above findings.













Plan of Correction:

Around The Clock Nursing's policy was changed to include TB Assessment screening. This policy will be reviewed by the Governing Body by May 10, 2019. The findings will be reviewed with the Professional Advisory Board. TB Screening will be monitored during clinical record review to evaluate policy change until there is a 100% accuracy is noted for 6 consecutive months.


Initial Comments:

Based on the findings of an unannounced on-site state licensure survey conducted on March 11, 2019 through March 13, 2019, Around-The-Clock Nursing was found to be in compliance with the requirements of 28 Pa. Code, Part IV, Health Facilities, and Subpart A. Chapter 51.




Plan of Correction:




Initial Comments:

Based on the findings of an unannounced on-site state licensure survey conducted on March 11, 2019 through March 13, 2019, Around-The-Clock Nursing was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: