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.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:

Based on the findings of an 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:

An approved Plan of Correction is not on file.


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:

An approved Plan of Correction is not on file.


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:

An approved Plan of Correction is not on file.


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:

An approved Plan of Correction is not on file.


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:

An approved Plan of Correction is not on file.


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:

An approved Plan of Correction is not on file.


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: