QA Investigation Results

Pennsylvania Department of Health
ELITE HOME HEALTH CARE INC.
Health Inspection Results
ELITE HOME HEALTH CARE INC.
Health Inspection Results For:


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Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification survey conducted May 8, 2019, through May 10, 2019, and May 14, 2019, Elite Home Health Care, Inc. was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and 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 review of Casper reports, agency policy, clinical records (CR) and interview with the administrator, alternate administrator and assistant director of nursing trainee, the agency failed to follow its policy regarding transmitting OASIS (outcome and assessment information set) for two (2) of two (2) clinical records receiving skilled services over the age of eighteen. (CR # 3 and 7)

Findings included:

Review of Casper reports on May 7, 2019 at 4:30 P.M. revealed that the agency had not submitted OASIS from February, 2018 to January, 2019.

When asked for validation reports on May 9, 2019 at 2:00 P.M., the administrator stated that she was not aware that the agency needed to transmit OASIS because the agency "only provides care to pediatric and Waiver patients. We stopped providing Medicare services."

There were no validation reports to review.

Review of agency policy #IM-6.0 "Reporting OASIS Information" on May 10, 2019, at 10:30 A.M. revealed: Policy: "Elite Home Health Care reports, encodes, ensures the accuracy of and transmits Outcome Assessment Information Set (OASIS) data consistent with the Centers for Medicare and Medicaid Services (CMS) requirements. Procedure: 1. The agency reports OASIS data on all applicable patients at least once a month... 2. OASIS data is collected by a Registered Nurse (RN), Physical therapist (PT), Occupational Therapist (OT) or Speech Language Pathologist (SLP) as part of the comprehensive assessment at the required time points. A. An RN collects OASIS data at: i. Start of care, within 48 hours, ii. Resumption of care, within 48 hours of notification, iii. follow-up, within the last 5 days of the certification period. B. An RN, PT, OT, or SLP collects data at: i. Transfer to an inpatient facility with or without discharge from the agency within 48 hours of notification. ii. Discharge to the community, within 48 hours of notification, iii. Death at home, within 48 hour of notification.... 3. The agency electronically transmits accurate completed encoded and locked data for each patient to the State DOH at least monthly...."

Review of clinical records on May 9, 2019, from approximately 9:00 A.M. to 2:30 P.M. revealed the following:

CR #3, start of care January 22, 2018. The CR contained no evidence of a comprehensive OASIS assessment or transmission of OASIS data on admission or at the time of recertification for any of the subsequent recertification periods.

CR #7, start of care February 11, 2019. The CR contained no evidence of a comprehensive OASIS assessment or transmission of OASIS data on admission or upon transfer to the hospital on February 20, 2019, or upon discharge at the end of the certification period, April 11, 2019.

Interview with the administrator, alternate administrator, and assistant director of nursing trainee on May 10, 2019, at approximately 11:30 A.M. confirmed that the agency has not been completing comprehensive OASIS assessments or transmitting OASIS data.
































Plan of Correction:

Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies .
It was determined that the Administrator will be responsible for setting up user identification and password, working with the state agency OASIS coordinator to establish connectivity with the OASIS system and successfully transmit test data to the QIES ASAP system or CMS .
(This process might take longer than expected date of completion. The Department of Health will be notified if any unavoidable delays to this process occur)
" REPORTING OASIS INFORMATION "Policy will be reviewed and updated as needed by the Professional Advisory Committee. All RN's responsible for patient assessments and OASIS data collection will be in-serviced on policy, which includes required time frames for data collection on all types of assessments as well as to the OASIS Guidance Manual, CMS ,CoP and State Regulations concerning OASIS Encoding and transmission. Administrator will oversee the scheduling of all overdue Assessments. A tracking system will be put in place for all assessments and OASIS submissions. Each patient must receive a patient-specific, comprehensive assessment. Comprehensive assessment must accurately reflect the patient's status at the time of the assessment, and must include OASIS required data. RNs will visit each patient to perform assessment and collect data, the date of the actual data collection for all late assessments completed will be reported as the actual date of completion. Proper documentation will be placed in patient's clinical record describing the circumstances surrounding the late submissions. RN's conducting assessment will encode and transmit OASIS data (in a format specified by CMS) using the software available from CMS or software that conforms to CMS standard electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set.
On a weekly basis (Fridays) Administrator will check and confirm that all scheduled assessment visits due that week were performed and data encoded and transmitted Verification transmissions will be printed following each transmission and placed in tracking record for review and crossed checked against assessments by Assistant administrator and Nursing Supervisor to ensure all OASIS assessments performed on all applicable patients receiving Skilled Services. Tracking system will be updated weekly to ensure each transmission is made no later than 30 days.
The above weekly procedure will remain in place until 100% compliance is achieved and every 90 days thereafter. Any possible future changes to this plan will be discussed as needed during quarterly quality management meeting reviews.
Administrator responsible for implementation
Correction Date: 7/13/2019



484.55(b)(1) ELEMENT
5 calendar days after start of care

Name - Component - 00
The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care.

Observations:


Based on review of agency policy, clinical records (CR) and an interview with the agency administrator, alternate administrator, and assistant director of nursing trainee, the agency failed to complete the comprehensive assessment within 48 hours of referral, or within 48 hours of the patients return home, or on the physician- ordered start of care date for three (3) of seven (7) clinical records (CR#3, 6, and 7).

Findings included:

A review of agency Policy # C-3.0 "Comprehensive Assessment of Patient and Coordination of Care" conducted on May 10, 2019, at approximately 10:30 A.M. states, "Procedure: 1. RN Completes Comprehensive Assessment: Patients admitted to Elite Home Health Care receive a patient specific comprehensive assessment at the Start of Care completed by a Registered Nurse (RN) A. The RN completes the comprehensive assessment as part of the initial assessment and admission process (see Policy # C-1.0... ) consistent with the patient's immediate needs, but no later than five (5) calendar days after the start of care..."

A review of clinical records conducted on May 9, 2019, from approximately 9:00 A.M. to 2:30 P.M. revealed the following:

CR#3, start of care January 22, 2018. No documentation of completion of an comprehensive assessment was contained in the CR.

CR#6, start of care August 21, 2017. An initial visit was conducted on August 21, 2018, there was no documentation of completion of a comprehensive assessment in the CR.

CR#7, start of care February 11, 2019. An initial visit was conducted on February 12, 2019, there was no documentation of completion of a comprehensive assessment in the CR.

An interview was conducted with the administrator, alternate administrator, assistant director of nursing trainee, and the operations manager on May 10, 2019, at approximately 11:30 A.M. confirmed the above findings.















Plan of Correction:

Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies
" Comprehensive Assessment of Patient and Coordination of Care " "Policy will be reviewed and updated as needed by the Professional Advisory Committee. All RN's responsible for patient admissions and comprehensive assessments will be in-serviced on policy, (which includes required time frame of 5 days after the start of care for all patients over the age of 18 receiving skilled nursing hours to complete comprehensive assessments) as well as to CMS, CoP and State Regulations concerning comprehensive assessments. Administrator will be responsible for admission team staffing and overseeing the scheduling of all patient admissions. Initial visits will be scheduled with RN designated to do admission for no later than 48 hours after referral is obtained. A tracking system will be put in place for all patients who were admitted to agency and date in which comprehensive assessment is due. Each admitting RN will confirm the schedule of each opening assigned to them, will visit each patient to perform comprehensive m assessment, collect data and will mark on tracking spread sheet that comprehensive assessment was performed within 5 days after the start of care.
On a monthly basis ,Administrator will check tracking spreadsheets and confirm that all scheduled visits and comprehensive assessments due each week were performed and placed in patients CR ( for applicable patients, data encoded and transmitted) .Spreadsheets will be crossed-checked against the Clinical Records by Assistant administrator and Nursing Supervisor to ensure all comprehensive assessments are performed on all patients receiving Home Health Services. Tracking system will be updated weekly to ensure each comprehensive assessment is made within 5 days after the start of care.
- This includes: CR# 3,6 and 7
In the event that a comprehensive assessment or admission is performed past the 5 days after the start of care. time frame, visit will be scheduled as soon as possible after the oversight is identified. Proper documentation will be placed in patient's clinical record describing the circumstances surrounding the late submissions as well as documentation of physician being notified of a delayed start of care. The date of the actual visit for all late initial assessments completed will be reported as the actual date of completion. Administrator will oversee the scheduling of all past due Assessments and ensure that all patients admitted to the agency are current with comprehensive assessments. Proper actions will be taken by Administration once the root cause for the oversight has been established.
The above monthly procedure will remain in place until 100% compliance is achieved and every 90 days thereafter. Any possible future changes to this plan will be discussed as needed during quarterly quality management meetings.
Responsible person(s): Administrator and DON
Date of Completion : July 13,2019

CR#3
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies
" Comprehensive Assessment of Patient and Coordination of Care " "Policy will be reviewed and updated as needed by the Professional Advisory Committee. All RN's responsible for patient admissions and comprehensive assessments will be in-serviced on policy, (which includes required time frame of 5 days after the start of care for all patients over the age of 18 receiving skilled nursing hours to complete comprehensive assessments) as well as to CMS, CoP and State Regulations concerning comprehensive assessments. Administrator will be responsible for admission team staffing and overseeing the scheduling of all patient admissions. Initial visits will be scheduled with RN designated to do admission for no later than 48 hours after referral is obtained. A tracking system will be put in place for all patients who were admitted to agency and date in which comprehensive assessment is due. Each admitting RN will confirm the schedule of each opening assigned to them, will visit each patient to perform comprehensive m assessment, collect data and will mark on tracking spread sheet that comprehensive assessment was performed within 5 days after the start of care.
On a monthly basis ,Administrator will check tracking spreadsheets and confirm that all scheduled visits and comprehensive assessments due each week were performed and placed in patients CR ( for applicable patients, data encoded and transmitted) .Spreadsheets will be crossed-checked against the Clinical Records by Assistant administrator and Nursing Supervisor to ensure all comprehensive assessments are performed on all patients receiving Home Health Services. Tracking system will be updated weekly to ensure each comprehensive assessment is made within 5 days after the start of care.
- This includes: CR# 3,6 and 7
In the event that a comprehensive assessment or admission is performed past the 5 days after the start of care. time frame, visit will be scheduled as soon as possible after the oversight is identified. Proper documentation will be placed in patient's clinical record describing the circumstances surrounding the late submissions as well as documentation of physician being notified of a delayed start of care. The date of the actual visit for all late initial assessments completed will be reported as the actual date of completion. Administrator will oversee the scheduling of all past due Assessments and ensure that all patients admitted to the agency are current with comprehensive assessments. Proper actions will be taken by Administration once the root cause for the oversight has been established.
The above monthly procedure will remain in place until 100% compliance is achieved and every 90 days thereafter. Any possible future changes to this plan will be discussed as needed during quarterly quality management meetings.
Responsible person(s): Administrator and DON
Date of Completion : July 13,2019

CR#6
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies
" Comprehensive Assessment of Patient and Coordination of Care " "Policy will be reviewed and updated as needed by the Professional Advisory Committee. All RN's responsible for patient admissions and comprehensive assessments will be in-serviced on policy, (which includes required time frame of 5 days after the start of care for all patients over the age of 18 receiving skilled nursing hours to complete comprehensive assessments) as well as to CMS, CoP and State Regulations concerning comprehensive assessments. Administrator will be responsible for admission team staffing and overseeing the scheduling of all patient admissions. Initial visits will be scheduled with RN designated to do admission for no later than 48 hours after referral is obtained. A tracking system will be put in place for all patients who were admitted to agency and date in which comprehensive assessment is due. Each admitting RN will confirm the schedule of each opening assigned to them, will visit each patient to perform comprehensive m assessment, collect data and will mark on tracking spread sheet that comprehensive assessment was performed within 5 days after the start of care.
On a monthly basis ,Administrator will check tracking spreadsheets and confirm that all scheduled visits and comprehensive assessments due each week were performed and placed in patients CR ( for applicable patients, data encoded and transmitted) .Spreadsheets will be crossed-checked against the Clinical Records by Assistant administrator and Nursing Supervisor to ensure all comprehensive assessments are performed on all patients receiving Home Health Services. Tracking system will be updated weekly to ensure each comprehensive assessment is made within 5 days after the start of care.
- This includes: CR# 3,6 and 7
In the event that a comprehensive assessment or admission is performed past the 5 days after the start of care. time frame, visit will be scheduled as soon as possible after the oversight is identified. Proper documentation will be placed in patient's clinical record describing the circumstances surrounding the late submissions as well as documentation of physician being notified of a delayed start of care. The date of the actual visit for all late initial assessments completed will be reported as the actual date of completion. Administrator will oversee the scheduling of all past due Assessments and ensure that all patients admitted to the agency are current with comprehensive assessments. Proper actions will be taken by Administration once the root cause for the oversight has been established.
The above monthly procedure will remain in place until 100% compliance is achieved and every 90 days thereafter. Any possible future changes to this plan will be discussed as needed during quarterly quality management meetings.
Responsible person(s): Administrator and DON
Date of Completion : July 13,2019

CR#7
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies
" Comprehensive Assessment of Patient and Coordination of Care " "Policy will be reviewed and updated as needed by the Professional Advisory Committee. All RN's responsible for patient admissions and comprehensive assessments will be in-serviced on policy, (which includes required time frame of 5 days after the start of care for all patients over the age of 18 receiving skilled nursing hours to complete comprehensive assessments) as well as to CMS, CoP and State Regulations concerning comprehensive assessments. Administrator will be responsible for admission team staffing and overseeing the scheduling of all patient admissions. Initial visits will be scheduled with RN designated to do admission for no later than 48 hours after referral is obtained. A tracking system will be put in place for all patients who were admitted to agency and date in which comprehensive assessment is due. Each admitting RN will confirm the schedule of each opening assigned to them, will visit each patient to perform comprehensive m assessment, collect data and will mark on tracking spread sheet that comprehensive assessment was performed within 5 days after the start of care.
On a monthly basis ,Administrator will check tracking spreadsheets and confirm that all scheduled visits and comprehensive assessments due each week were performed and placed in patients CR ( for applicable patients, data encoded and transmitted) .Spreadsheets will be crossed-checked against the Clinical Records by Assistant administrator and Nursing Supervisor to ensure all comprehensive assessments are performed on all patients receiving Home Health Services. Tracking system will be updated weekly to ensure each comprehensive assessment is made within 5 days after the start of care.
- This includes: CR# 3,6 and 7
In the event that a comprehensive assessment or admission is performed past the 5 days after the start of care. time frame, visit will be scheduled as soon as possible after the oversight is identified. Proper documentation will be placed in patient's clinical record describing the circumstances surrounding the late submissions as well as documentation of physician being notified of a delayed start of care. The date of the actual visit for all late initial assessments completed will be reported as the actual date of completion. Administrator will oversee the scheduling of all past due Assessments and ensure that all patients admitted to the agency are current with comprehensive assessments. Proper actions will be taken by Administration once the root cause for the oversight has been established.
The above monthly procedure will remain in place until 100% compliance is achieved and every 90 days thereafter. Any possible future changes to this plan will be discussed as needed during quarterly quality management meetings.
Responsible person(s): Administrator and DON
Date of Completion : July 13,2019



484.55(d)(1)(i,ii,iii) ELEMENT
Last 5 days of every 60 days unless:

Name - Component - 00
The last 5 days of every 60 days beginning with the start-of-care date, unless there is a-
(i) Beneficiary elected transfer;
(ii) Significant change in condition; or
(iii) Discharge and return to the same HHA during the 60-day episode.

Observations:


Based on review of agency policy, clinical records (CR) and interview with agency staff, the agency failed to complete a comprehensive assessment within five (5) days of the end of the certification period for two (2) of seven (7) CR reviewed. (CR # 2 and 3)

Findings included:

Review of agency policy #C-3.0 "Comprehensive Assessment of Patient and Coordination of Care" on May 10, 2019, at approximately 10:30 A.M. states, "Procedure: 6. Update of the Comprehensive Assessment: An RN or the appropriate clinician (based on the therapy exception noted in 1.C above), updates and revises the comprehensive assessment regularly (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than: A. every 60 days beginning with the start-of-care date..."

Review of clinical records conducted on May 9, 2019, from approximately 9:00 A.M. to 2:30 P.M. revealed the following:

CR #1, start of care August 14, 2017, contained a comprehensive assessment completed on April 15, 2019, for the certification period April 6, 2019, through June 4, 2019, which was not completed the last 5 days of the certification period. A comprehensive assessment completed on December 17, 2018, for the certification period December 6, 2018, through February 4, 2019, which was not completed the last 5 days of the certification period.

CR #2, start of care December 18, 2018, contained a comprehensive assessment completed on March 11, 2019, for the certification period February 19, 2019, through April 19, 2019, which was not completed the last 5 days of the certification period.

CR #3, start of care January 22, 2018, contained a comprehensive assessment completed on November 14, 2018, for the certification period November 15, 2018, through January 14, 2019; and a comprehensive assessment completed on March 18, 2019, for the certification period March 18, 2019, through May 16, 2019. There was no documentation of a comprehensive assessment completed the last 5 days of the certification period for the certification period January 16, 2019, through March 17, 2019.

An interview with the administrator, alternate administrator, assistant director of nursing trainee, and operations manager on May 10, 2019, at approximately 11:300 A.M. confirmed the above findings.



















Plan of Correction:

CR#2
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies
" Comprehensive Assessment of Patient and Coordination of Care " "Policy will be reviewed and updated as needed by the Professional Advisory Committee. All RN's responsible for patient admissions and comprehensive assessments will be in-serviced on policy, (which includes required time frame of last 5 days of every 60 days beginning with SOC date) for all patients over the age of 18 receiving skilled nursing hours to complete comprehensive assessments) as well as to CMS, CoP and State Regulations concerning comprehensive assessments.
Administrator will be responsible for team staffing and overseeing the scheduling of all patient assessments. Follow up assessment visits will be scheduled with RN designated to do admission for no later than within the last 5 days of every 60. A tracking system will be put in place for all active patients and date in which comprehensive assessment is due, . Each assigned RN will confirm the schedule of each assessment visit assigned to them, will visit each patient to perform comprehensive assessment, collect data and will mark on tracking spread sheet that comprehensive assessment was performed within the last 5 days of every 60.
- This includes: CR #2 and 3
On a monthly basis ,Administrator will check tracking spreadsheets and confirm that all scheduled visits and comprehensive assessments due each week were performed and placed in patients CR ( for applicable patients, data encoded and transmitted) .Spreadsheets will be crossed-checked against the Clinical Records by Assistant administrator and Nursing Supervisor to ensure all comprehensive assessments are performed on all patients receiving Home Health Services. Tracking system will be updated weekly to ensure each follow up comprehensive assessment is made within the last 5 days of every 60.
In the event that a comprehensive assessment is performed past the last 5 days of every 60 time frame, visit will be scheduled as soon as possible after the oversight is identified. Proper documentation will be placed in patient's clinical record describing the circumstances surrounding the late submissions as well as documentation of physician being notified of a delayed assessment . The date of the actual visit for all late initial assessments completed will be reported as the actual date of completion. Administrator will oversee the scheduling of all past due Assessments and ensure that all patients admitted to the agency are current with comprehensive assessments. Proper actions will be taken by Administration once the root cause for the oversight has been established.
Responsible person(s): Administrator and DON
Date of Completion : July 13,2019

CR#3
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies
" Comprehensive Assessment of Patient and Coordination of Care " "Policy will be reviewed and updated as needed by the Professional Advisory Committee. All RN's responsible for patient admissions and comprehensive assessments will be in-serviced on policy, (which includes required time frame of last 5 days of every 60 days beginning with SOC date) for all patients over the age of 18 receiving skilled nursing hours to complete comprehensive assessments) as well as to CMS, CoP and State Regulations concerning comprehensive assessments.
Administrator will be responsible for team staffing and overseeing the scheduling of all patient assessments. Follow up assessment visits will be scheduled with RN designated to do admission for no later than within the last 5 days of every 60. A tracking system will be put in place for all active patients and date in which comprehensive assessment is due, . Each assigned RN will confirm the schedule of each assessment visit assigned to them, will visit each patient to perform comprehensive assessment, collect data and will mark on tracking spread sheet that comprehensive assessment was performed within the last 5 days of every 60.
- This includes: CR #2 and 3
On a monthly basis ,Administrator will check tracking spreadsheets and confirm that all scheduled visits and comprehensive assessments due each week were performed and placed in patients CR ( for applicable patients, data encoded and transmitted) .Spreadsheets will be crossed-checked against the Clinical Records by Assistant administrator and Nursing Supervisor to ensure all comprehensive assessments are performed on all patients receiving Home Health Services. Tracking system will be updated weekly to ensure each follow up comprehensive assessment is made within the last 5 days of every 60.
In the event that a comprehensive assessment is performed past the last 5 days of every 60 time frame, visit will be scheduled as soon as possible after the oversight is identified. Proper documentation will be placed in patient's clinical record describing the circumstances surrounding the late submissions as well as documentation of physician being notified of a delayed assessment . The date of the actual visit for all late initial assessments completed will be reported as the actual date of completion. Administrator will oversee the scheduling of all past due Assessments and ensure that all patients admitted to the agency are current with comprehensive assessments. Proper actions will be taken by Administration once the root cause for the oversight has been established.
Responsible person(s): Administrator and DON
Date of Completion : July 13,2019



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 may choose to include.

Observations:


Based on review of agency policies, clinical records (CR), and interviews with the administrator, the alternate administrator, and the assistant director of nursing trainee, the agency failed to ensure that the "Home Health Certification and Plan of Care" (POC) included detailed physician orders for all care to be provided for five (5) of seven (7) CR reviewed. (CR # 2, 3, 4, 6 and 7)

Findings included:

On May 10, 2019, at approximately 10:30 A.M., review of the agency policy # C-2.0 titled "Acceptance of Patients, Plan of Treatment/Care and Medical Supervision" revealed the following:
" Procedure: 2. Plan of Care: Care follows a written plan of care established and periodically reviewed by a doctor of medicine, osteopathy or podiatric medicine (physician). A. The plan of care is established by the appropriate agency staff after consultation with the physician, other agency personnel, patient, family and/or caregiver. B. The plan includes: i. Pertinent Diagnosis, ii. Mental Status, iii. Types of services and equipment required, iv. Frequency of visits, v. Prognosis, vi. Rehabilitation potential, vii. Functional limitations. Viii. Activities permitted, ix. Nutritional requirements, x. Medications & treatments, xi. Safety measures to protect against injury, xii. Instructions for timely discharge or referral, xiii. Any other pertinent items, xiv. Orders of therapy services include the specific procedures and modalities to be used, and the amount, frequency and duration of treatment ... "

Review of clinical records (CR) on May 9, 2019, from approximately 9:00 A.M. to 2:30 P.M. revealed the following:

CR #2, start of care December 21, 2018. Diagnoses include tracheostomy status (presence of a tracheostomy tube to maintain the airway), apnea not elsewhere classified (cessation of breathing), anemia of prematurity (low iron) and gastrostomy status (feeding tube inserted through abdomen into stomach).
Review of Orders for Discipline and Treatment for certification period April 20, 2019, through June 18, 2019 revealed the following:
Skilled nursing 8 hours per night, Friday, Saturday, and Sunday: 10PM to 6AM
To cover any additional shifts not staffed by primary agency.
To assess all body systems with a special attention to the respiratory system.
Vital signs every shift: Temperature, Respirations, Pulse, and Pulse Ox (measurement of oxygen saturation). Report any abnormal findings to the primary caregiver, MD, and supervisor.
Assess and maintain airway patency at all times. Tracheal suction as needed or as directed by primary caregivers. Perform trach (tracheostomy) care every 8 hours; cleanse with mild soap and water, pat dry, apply 2x2 drain sponge around trach site. Weekly trach changes with mom and SN (skilled nurse). Assess for signs of skin breakdown; redness irritation, or moisture.
Monitor and report abnormal secretory findings.
Assess and maintain skin integrity every shift.
Administer feedings as ordered, maintain aspiration precautions at all times.
Assess tolerance to feeds and monitor and report any signs and symptoms of feeding intolerance.
Administer medications via G-tube (gastrostomy tube). Flush G-tube with 3 mL(milliliters) of water after medications and feeds. Assess G-tube patency and site.
Monitor and report any adverse effects to primary caregiver, MD (medical doctor), and nursing supervisor.
Report all changes to from baseline to primary caregiver, MD, and nursing supervisor.
Maintain patient safety at all times.
Trach (tracheostomy tube) size: 3.5 Bivona Flex
Will begin sprints (short periods of time off the ventilator) to HME (heat and moisture exchanger) for 15-30 minutes twice a day as tolerated.
Call the Pulmonary department TDC program weekly with updates on the monitoring parameters listed below, which will determine readiness for wean.
*Continued weight gain or growth is just as important as all other vital signs*
Monitoring Parameters:
Monitor work of breathing, adequate level of daytime wakefulness and activity/tolerance of therapies.
Check these vital signs just before the wean starts and again before returning to the usual ventilator settings; Sp02 (peripheral capillary oxygen saturation or estimated oxygen level in blood), EtCO2 (end-tidal carbon dioxide), HR (heart rate), and RR (respiratory rate). As the wean times increase, monitor the vital signs every hour.
If the HR or RR increases more than 20% or the saturations decrease to less than 92%, stop the wean.
Also obtain ETCO2 before the wean/sprint and at the end of the wean/sprint prior to going back on the higher settings or vent. If you need to end the sprint early, obtain an ETCO2 and full vital signs.
Weight will need to be checked on a weekly basis, using the same scale at the same time of day, ideally while naked or with a dry diaper. "

The Orders for Discipline and Treatment lack the following details:

Frequency and duration of skilled nursing services
Volume of tracheostomy tube cuff, emergency tracheostomy tube change instructions, frequency of tracheostomy tie changes.
Ventilator make/model, ventilator settings, including mode, peak inspiratory pressure (PIP), PEEP (positive end expiratory pressure), fraction of inspired oxygen (FiO2), inspiratory time, tidal volume, respiratory rate, heat and humidification, alarm settings, ventilator circuit change frequency.
Frequency, suction catheter type/size, depth of suctioning.
Size and type of G-tube, the amount of water to be instilled into the cuff, frequency of G-tube changes, frequency of assessment of G-tube patency and site, G-tube care procedure and frequency.

CR #3, start of care January 22, 2018. Diagnoses include cerebral palsy (congenital disorder of movement, muscle tone, or posture), unspecified, neuromuscular scoliosis (curvature of the spine), site unspecified, pseudobulbar affect (pathological laughter and crying), unspecified asthma (constriction of airways), uncomplicated.
Review of Orders for Discipline and Treatment for certification period March 18, 2019, through May 16, 2019 revealed the following orders that do not contain sufficient detail:
SN (skilled nursing) 28 hours a week, 4 visits a day:
To assess all body systems and report abnormal findings to MD (medical doctor)
Vital signs every visit
Assess lung sounds and respiratory effort every visit
Straight cath (catheterization) four times a day
Monitor for signs of urinary tract infections, report to MD any unusual findings
Record urinary output every visit
Incontinent care as needed
Assess skin for signs of breakdown, report to MD any unusual findings
Provide safety at all times

The Orders for Discipline and Treatment lack the following details:

Duration of skilled nursing services
Type and size of catheter to be used for straight catheterization

CR #4, start of care March 16, 2019. Diagnoses include congenital malformation of heart, unspecified, ventricular septal defect (abnormal connection between the lower chambers of the heart), stenosis of pulmonary artery (narrowing of the blood vessel that carries blood from the right ventricle of the heart to the lungs), gastrostomy status.
Review of Orders for Discipline and Treatment for certification period March 18, 2019, through May 16, 2019 revealed the following:
Skilled nursing 24 hours a week; 12 hours Saturday and 12 hours Sunday, and to provide coverage for other agency
Perform and assess vital signs: Temperature, HR, RR, and B/P (blood pressure) as tolerated by (patient). Assess all body systems, patient/caregiver knowledge of disease process and associated care and treatment, medication regimen, knowledge and signs and symptoms of complications necessitating medical attention.
Assess, teach, manage, evaluate, and perform fall prevention intervention. Maintain constant supervision of (patient) and ensure safety at all times.
Perform interventions to monitor and mitigate pain. Use FLACC (face, legs, activity, cry, consolability scale) to help assess for signs of pain.
Assess for signs and symptoms of complication and infection to include redness, open areas, elevation in temperature. Perform full skin assessment every shift. Change frequently and as needed, but no less than every two hours. Report any abnormal findings to primary caregiver, supervisor and MD.
Assess respiratory status. Perform methods to recognize pulmonary dysfunction and relieve complications.
Assess cardiac status for methods to recognize and relieve complications. Report any signs of decreased cardiac output immediately to primary caregiver, MD and supervisor. (abnormal HR, low blood pressure, prolonged capillary refill, changes in mental status etc.)
Weigh patient per MD visit and update agency following each visit.
Perform measures to manage, recognize and relieve symptoms of GERD; administer medications as prescribed, proper positioning during meals, etc.
Perform measuring and recording of intake and output
Manage gastrostomy tube as follows: 1. Assess site at the start and end of each shift. Check placement. Clean with soap and water every shift and pat dry. Apply 2x2 if available. Report any and all abnormal findings to primary caregiver, supervisor, and MD.
Manage enteral nutrition as follows Monogan formula run continuously at 35 mL/hr via G-tube with care of equipment to include feeding pump, pole, feeding bags and extension tubing. Perform gastrostomy tube flush with 10 mL of water after each feed.
Assess changes in level of consciousness or neurological status
Perform circulatory checks report any discoloration or prolonged refill time immediately
Perform medication set up and compliance. Perform medication regimen to include name, dose, frequency, route, desired action, side effects, interactions, adverse reactions, recognition of problems and how to report.
Flush G-tube with 5 mL of water after each medication.
*Report any and all abnormal findings to primary caregiver, MD, and supervisor immediately
*Report all changes in medications to supervisor immediately

The Orders for Discipline and Treatment lack the following details:

Duration of skilled nursing services
Size and type of G-tube, amount of water to be instilled into the cuff, frequency of G-tube changes.

CR #6, start of care August 21, 2017. This patient has been hospitalized effective April 15, 2019. Diagnoses include other reduction deformities of brain (abnormally small convolutions in the brain), chronic respiratory failure, unspecified with hypoxia (lack of oxygen) or hypercapnia (elevated levels of carbon dioxide in the blood), parainfluenza virus pneumonia, lobar pneumonia (affects a large area of the lobe of the lung), unspecified organism, unspecified lack of expected normal physiological development in childhood, other cerebral palsy, Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus, tachypnea (rapid breathing), not elsewhere classified, Gastrostomy status.
Review of Orders for Discipline and Treatment for certification period April 13, 2019, through June 11, 2019 revealed the following:
Skilled Nursing 16 Flex hours on weekends when parents work, a continuation of overnight nursing from 11PM to 7AM, 7 days per week, to allow mom to sleep at night, complete household chores, shop, go to church, to tend family needs and care for her other 4 children's needs, and provide a safe environment for (patient) while she is out of the home.
To assess all body systems with attention to respiratory system: to assess respiratory rate, lung sounds work of breathing and secretory status.
Vital signs every shift: temperature, heart rate, blood pressure when possible.
Continuous pulse ox monitoring, may remove probe during bath and to replace, oxygen up to 3 LPM as needed to maintain a pulse ox above 92%. Notify MD if need to titrate to 3 LPM or more.
Assess patency of G-tube, and site
G-tube feedings as prescribed, followed by 100 ml flush
Assess and monitor for signs and symptoms of feeding intolerance: report to supervisor, MD, and caregiver
Assess bowel sounds, document all bowel movements, Report any abnormal findings.
Assess for signs of infection and report abnormal findings to supervisors, MD, and caregiver.
Maintain aspiration precautions at all times.
Chest PT (physiotherapy) 5 minutes, 4 times a day as tolerated
Percussion vest: Pressure control 30: frequency 1 -6 hertz- for 10 minutes, frequency 2- 10 hertz for 10 minutes, frequency 3- 12 hertz for 10 minutes.
Cough assist: positive pressure 25, negative pressure 25: 5 reps (repetitions), twice a day
Suction s needed: document amount, color, consistency, of secretions as well as frequency of suctioning.
BiPAP overnight: IPAP 20, EPAP 14, rate of 18, oxygen 2 LPM (liters per minute)
Maintain seizure precautions at all times: document time, type, and frequency of seizures. Administer emergency seizure mediation as ordered. Notify mother, and MD upon emergency drug administration. Document all communications.
Maintain safety at all times
Incontinence care every two hours and as needed
Turn and reposition every two hours and as needed to maintain comfort.
Maintain skin integrity at all times: monitor for signs of breakdown and report any abnormal findings to supervisor, MD and caregiver.


The Orders for Discipline and Treatment lack the following details:

Frequency and duration of skilled nursing services
Assessment of patency of G-tube and site does not list a frequency

CR #7, start of care February 11, 2019. Diagnoses include paraplegia (paralysis of the lower half of the body), unspecified, pressure ulcer of other site, stage 2, chronic respiratory failure, unspecified with hypoxia or hypercapnia, urinary tract infection, site not specified, major depressive disorder, recurrent severe without psychotic features, vitamin deficiency, unspecified, dysphagia (difficulty swallowing), unspecified, pain, unspecified, acquired absence of right leg above knee, cachexia (weakness and wasting of the body), gastrostomy status.
Review of Orders for Discipline and Treatment for certification period February 11, 2019, through April 11, 2019 revealed the following:
Skilled nursing Monday - Sunday, 24 hours a day
Skilled assessment of all systems and report abnormal findings to MD
Vital signs once a shift as tolerated: Temperature, HR (heart rate), RR (respiratory rate), and blood pressure
Document any refusal/noncompliance of care/medication administration in progress notes.
Patient education and teaching on disease process and medication management including side effects
Patient education on all safety and infection precautions instruct on when and why to contact MD
Educate patient on urgent versus non-urgent care needs
Perform chest PT (physiotherapy) as tolerated and as allowed, document all noncompliance/refusal
Report any abnormal findings or worsening of wounds to supervisor, family and MD
Keep HOB elevated 30 degrees, and maintain aspiration precautions during meals.
Maintain airway patency at all times.
Provide safety at all times through constant supervision
Maintain Peg tube, check for patency and placement before administering medications
Assess Peg tube site daily for signs of inflammation/infection (redness, drainage, odor), Report to MD
Assess indwelling catheter every shift for signs of infection, provide catheter and perianal care every shift
Flush foley with 30 ml water every shift to ensure patency and placement
Empty foley drainage bag and document output as well as urine color, odor, and consistency every shift.
Wound care:
Cleanse wounds with normal saline and pat dry
Apply Bactroban ointment twice a day to affected areas.


The Orders for Discipline and Treatment lack the following details:

Duration of skilled nursing services
Frequency and duration of chest PT
Frequency of wound care and location of wounds
Size and type of tube, frequency of Peg tube changes
Type and size of indwelling catheter, frequency of changes, details of catheter care or perianal care to be performed

An interview with the agency administrator, alternate administrator and the alternate director of nursing trainee on May 10, 2019, at approximately 11:30 A.M. confirmed the above findings.




































Plan of Correction:

CR#2
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator and Nursing department to discuss PA DOH deficiencies from 05/14/2019
Acceptance of patients/plan of treatment/care and medical supervision policies will be reviewed and updated as needed to ensure it includes information regarding the detailed components of the plan of care (outlined in 484.60 Condition of participation: Care planning, coordination of services, and quality of care).
The Administrator will schedule training sessions for all Nurses to provide education in the components of a patients plan of care as well as to CMS CoP and State Regulations concerning Plan of Treatment.
Clinical record audits will be performed on 100% of patients to determine elements/details individual plans of care currently lack.
Updates/addendums will be created to add specific details that are missing in patients 485's,including but not limited to:
a. Frequency and Duration of services
b. Frequency of treatments, including instruction
c. Supplies used to administer treatments, identifying model, type ,size , such as catheters used for catheterization, indwelling catheters and suction catheters.
d. Indwelling catheter/Perineal care instructions
e. Tracheostomy tube make, size, uncuffed/cuffed, volume of cuff, with changing frequencies and instructions. Tracheostomy care and patency check instructions and frequency.
f. Emergency track tube change equipment and instructions.
g. Feeding tubes (G, J or PEG) make, size, cuff water volume. Changing frequency, patency and site assessment frequency, tube care procedure and frequency.
h. Ventilators make/model, settings prescribed, documentation of settings checks frequency. Frequency of circuit change.
i. Specific wound care instructions including documentation of wound and location and progress/lack of.
All Addendums will be reviewed by DON and RN who created addendum prior to sending to Physician for review/approval All changes will be incorporated into the 485 document for next certification period.

Administrator and Quality management team member designee will audit 100% of clinical records previously audited to determine compliance.
On a Monthly basis , all 485's for new admissions will be reviewed by DON and RN who created plan of care/addendum to determine compliance in all areas of plan of care until 100% compliance is noted, then 25% of all admission will be audited quarterly during quarterly record reviews and quality management meetings to determine compliance. Administrator will review results. Additional actions needed will be determined during Quality Management Meetings.
Responsible person(s): Administrator and DON
Date of Completion : July 13,2019


CR#3
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator and Nursing department to discuss PA DOH deficiencies from 05/14/2019
Acceptance of patients/plan of treatment/care and medical supervision policies will be reviewed and updated as needed to ensure it includes information regarding the detailed components of the plan of care (outlined in 484.60 Condition of participation: Care planning, coordination of services, and quality of care).
The Administrator will schedule training sessions for all Nurses to provide education in the components of a patients plan of care as well as to CMS CoP and State Regulations concerning Plan of Treatment.
Clinical record audits will be performed on 100% of patients to determine elements/details individual plans of care currently lack.
Updates/addendums will be created to add specific details that are missing in patients 485's,including but not limited to:
a. Frequency and Duration of services
b. Frequency of treatments, including instruction
c. Supplies used to administer treatments, identifying model, type ,size , such as catheters used for catheterization, indwelling catheters and suction catheters.
d. Indwelling catheter/Perineal care instructions
e. Tracheostomy tube make, size, uncuffed/cuffed, volume of cuff, with changing frequencies and instructions. Tracheostomy care and patency check instructions and frequency.
f. Emergency track tube change equipment and instructions.
g. Feeding tubes (G, J or PEG) make, size, cuff water volume. Changing frequency, patency and site assessment frequency, tube care procedure and frequency.
h. Ventilators make/model, settings prescribed, documentation of settings checks frequency. Frequency of circuit change.
i. Specific wound care instructions including documentation of wound and location and progress/lack of.
All Addendums will be reviewed by DON and RN who created addendum prior to sending to Physician for review/approval All changes will be incorporated into the 485 document for next certification period.

Administrator and Quality management team member designee will audit 100% of clinical records previously audited to determine compliance.
On a Monthly basis , all 485's for new admissions will be reviewed by DON and RN who created plan of care/addendum to determine compliance in all areas of plan of care until 100% compliance is noted, then 25% of all admission will be audited quarterly during quarterly record reviews and quality management meetings to determine compliance. Administrator will review results. Additional actions needed will be determined during Quality Management Meetings.
Responsible person(s): Administrator and DON
Date of Completion : July 13,2019

CR#4
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator and Nursing department to discuss PA DOH deficiencies from 05/14/2019
Acceptance of patients/plan of treatment/care and medical supervision policies will be reviewed and updated as needed to ensure it includes information regarding the detailed components of the plan of care (outlined in 484.60 Condition of participation: Care planning, coordination of services, and quality of care).
The Administrator will schedule training sessions for all Nurses to provide education in the components of a patients plan of care as well as to CMS CoP and State Regulations concerning Plan of Treatment.
Clinical record audits will be performed on 100% of patients to determine elements/details individual plans of care currently lack.
Updates/addendums will be created to add specific details that are missing in patients 485's,including but not limited to:
a. Frequency and Duration of services
b. Frequency of treatments, including instruction
c. Supplies used to administer treatments, identifying model, type ,size , such as catheters used for catheterization, indwelling catheters and suction catheters.
d. Indwelling catheter/Perineal care instructions
e. Tracheostomy tube make, size, uncuffed/cuffed, volume of cuff, with changing frequencies and instructions. Tracheostomy care and patency check instructions and frequency.
f. Emergency track tube change equipment and instructions.
g. Feeding tubes (G, J or PEG) make, size, cuff water volume. Changing frequency, patency and site assessment frequency, tube care procedure and frequency.
h. Ventilators make/model, settings prescribed, documentation of settings checks frequency. Frequency of circuit change.
i. Specific wound care instructions including documentation of wound and location and progress/lack of.
All Addendums will be reviewed by DON and RN who created addendum prior to sending to Physician for review/approval All changes will be incorporated into the 485 document for next certification period.

Administrator and Quality management team member designee will audit 100% of clinical records previously audited to determine compliance.
On a Monthly basis , all 485's for new admissions will be reviewed by DON and RN who created plan of care/addendum to determine compliance in all areas of plan of care until 100% compliance is noted, then 25% of all admission will be audited quarterly during quarterly record reviews and quality management meetings to determine compliance. Administrator will review results. Additional actions needed will be determined during Quality Management Meetings.
Responsible person(s): Administrator and DON
Date of Completion : July 13,2019

CR#5
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator and Nursing department to discuss PA DOH deficiencies from 05/14/2019
Acceptance of patients/plan of treatment/care and medical supervision policies will be reviewed and updated as needed to ensure it includes information regarding the detailed components of the plan of care (outlined in 484.60 Condition of participation: Care planning, coordination of services, and quality of care).
The Administrator will schedule training sessions for all Nurses to provide education in the components of a patients plan of care as well as to CMS CoP and State Regulations concerning Plan of Treatment.
Clinical record audits will be performed on 100% of patients to determine elements/details individual plans of care currently lack.
Updates/addendums will be created to add specific details that are missing in patients 485's,including but not limited to:
a. Frequency and Duration of services
b. Frequency of treatments, including instruction
c. Supplies used to administer treatments, identifying model, type ,size , such as catheters used for catheterization, indwelling catheters and suction catheters.
d. Indwelling catheter/Perineal care instructions
e. Tracheostomy tube make, size, uncuffed/cuffed, volume of cuff, with changing frequencies and instructions. Tracheostomy care and patency check instructions and frequency.
f. Emergency track tube change equipment and instructions.
g. Feeding tubes (G, J or PEG) make, size, cuff water volume. Changing frequency, patency and site assessment frequency, tube care procedure and frequency.
h. Ventilators make/model, settings prescribed, documentation of settings checks frequency. Frequency of circuit change.
i. Specific wound care instructions including documentation of wound and location and progress/lack of.
All Addendums will be reviewed by DON and RN who created addendum prior to sending to Physician for review/approval All changes will be incorporated into the 485 document for next certification period.

Administrator and Quality management team member designee will audit 100% of clinical records previously audited to determine compliance.
On a Monthly basis , all 485's for new admissions will be reviewed by DON and RN who created plan of care/addendum to determine compliance in all areas of plan of care until 100% compliance is noted, then 25% of all admission will be audited quarterly during quarterly record reviews and quality management meetings to determine compliance. Administrator will review results. Additional actions needed will be determined during Quality Management Meetings.
Responsible person(s): Administrator and DON
Date of Completion : July 13,2019

CR#6
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator and Nursing department to discuss PA DOH deficiencies from 05/14/2019
Acceptance of patients/plan of treatment/care and medical supervision policies will be reviewed and updated as needed to ensure it includes information regarding the detailed components of the plan of care (outlined in 484.60 Condition of participation: Care planning, coordination of services, and quality of care).
The Administrator will schedule training sessions for all Nurses to provide education in the components of a patients plan of care as well as to CMS CoP and State Regulations concerning Plan of Treatment.
Clinical record audits will be performed on 100% of patients to determine elements/details individual plans of care currently lack.
Updates/addendums will be created to add specific details that are missing in patients 485's,including but not limited to:
a. Frequency and Duration of services
b. Frequency of treatments, including instruction
c. Supplies used to administer treatments, identifying model, type ,size , such as catheters used for catheterization, indwelling catheters and suction catheters.
d. Indwelling catheter/Perineal care instructions
e. Tracheostomy tube make, size, uncuffed/cuffed, volume of cuff, with changing frequencies and instructions. Tracheostomy care and patency check instructions and frequency.
f. Emergency track tube change equipment and instructions.
g. Feeding tubes (G, J or PEG) make, size, cuff water volume. Changing frequency, patency and site assessment frequency, tube care procedure and frequency.
h. Ventilators make/model, settings prescribed, documentation of settings checks frequency. Frequency of circuit change.
i. Specific wound care instructions including documentation of wound and location and progress/lack of.
All Addendums will be reviewed by DON and RN who created addendum prior to sending to Physician for review/approval All changes will be incorporated into the 485 document for next certification period.

Administrator and Quality management team member designee will audit 100% of clinical records previously audited to determine compliance.
On a Monthly basis , all 485's for new admissions will be reviewed by DON and RN who created plan of care/addendum to determine compliance in all areas of plan of care until 100% compliance is noted, then 25% of all admission will be audited quarterly during quarterly record reviews and quality management meetings to determine compliance. Administrator will review results. Additional actions needed will be determined during Quality Management Meetings.
Responsible person(s): Administrator and DON
Date of Completion : July 13,2019

CR#7
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator and Nursing department to discuss PA DOH deficiencies from 05/14/2019
Acceptance of patients/plan of treatment/care and medical supervision policies will be reviewed and updated as needed to ensure it includes information regarding the detailed components of the plan of care (outlined in 484.60 Condition of participation: Care planning, coordination of services, and quality of care).
The Administrator will schedule training sessions for all Nurses to provide education in the components of a patients plan of care as well as to CMS CoP and State Regulations concerning Plan of Treatment.
Clinical record audits will be performed on 100% of patients to determine elements/details individual plans of care currently lack.
Updates/addendums will be created to add specific details that are missing in patients 485's,including but not limited to:
a. Frequency and Duration of services
b. Frequency of treatments, including instruction
c. Supplies used to administer treatments, identifying model, type ,size , such as catheters used for catheterization, indwelling catheters and suction catheters.
d. Indwelling catheter/Perineal care instructions
e. Tracheostomy tube make, size, uncuffed/cuffed, volume of cuff, with changing frequencies and instructions. Tracheostomy care and patency check instructions and frequency.
f. Emergency track tube change equipment and instructions.
g. Feeding tubes (G, J or PEG) make, size, cuff water volume. Changing frequency, patency and site assessment frequency, tube care procedure and frequency.
h. Ventilators make/model, settings prescribed, documentation of settings checks frequency. Frequency of circuit change.
i. Specific wound care instructions including documentation of wound and location and progress/lack of.
All Addendums will be reviewed by DON and RN who created addendum prior to sending to Physician for review/approval All changes will be incorporated into the 485 document for next certification period.

Administrator and Quality management team member designee will audit 100% of clinical records previously audited to determine compliance.
On a Monthly basis , all 485's for new admissions will be reviewed by DON and RN who created plan of care/addendum to determine compliance in all areas of plan of care until 100% compliance is noted, then 25% of all admission will be audited quarterly during quarterly record reviews and quality management meetings to determine compliance. Administrator will review results. Additional actions needed will be determined during Quality Management Meetings.
Responsible person(s): Administrator and DON
Date of Completion : July 13,2019


484.60(d)(2) ELEMENT
Integrate all orders

Name - Component - 00
Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient.

Observations:


Based on review of agency policies, clinical records (CR), and interview with the agency staff, the agency failed to integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient for four (4) of seven (7) CR reviewed. (CR # 2, 3, 4, and 7).

Findings included:

On May 10, 2019, at 10:00 A.M., review of agency policy #C-12.0 Skilled Nursing Services states: Procedure: "1. The Nursing Supervisor coordinates, supervises and oversees the provision of nursing services. The Nursing Supervisor's role is to: B. Ensure that all personnel furnishing services maintain liaison and that their efforts are coordinated effectively, managed and follow the objectives outlined in the patient's plan of care. C. Guarantee that the clinical recorded or minutes of case conferences establish that effective interchange, reporting and coordination of patient care does occur. 2. Each patient at Elite Home Health Care is assigned a primary care RN. The primary care nurse is responsible for the following which is documented in each patients clinical record: B. Completing a comprehensive patient assessment which includes: ii. A review of all medications the patient is currently using to identify: a. any potential adverse effects and drug reactions, including ineffective drug therapy; b. any significant side effects and/or significant drug interactions; c. any duplicate drug therapies; and d. any non-compliance with drug therapy. c. Admission of patients for service and development of the patient care plan... I. Regular evaluation of the patient's progress, prompt action when any change in the patient's condition is noted or reported, and termination of care when goals of management are attained... R. Preparing and submitting required clinical record documentation... S. Informing physicians, home health care staff and interdisciplinary team members of changes in the patient's condition and needs... V. Participating in and completing the discharge planning process for patients.

A review of clinical records conducted on May 9, 2019, from 9:00 A.M. to 2:30 P.M revealed the following:

CR #2, start of care December 21, 2018. During the home visit (HV#2) conducted on May 8, 2019, at approximately 3:00 P.M., five (5) medications were noted on the Medication Treatment Record (in the home) for April, 2019, as discontinued. Furosemide (diuretic), Aldactazide (diuretic), Potassium chloride (electrolyte), Revatio (vasodilator), and Sodium Chloride tablet (electrolyte). On April 6, 2019, Cetirizine HCl (antihistamine) was added to the home Medication Treatment Record. There was no evidence that a verbal order was obtained for this medication, nor was the medication added to the medication profile.

CR #3, start of care January 22, 2018. During the home visit (HV#3) conducted on May 8, 2019, at approximately 3:45 P.M., the CR's medications were found in a dresser drawer. There were seven (7) bottles of various expired prescription medications. There were two (2) bottles of prescription medications with labels that were worn and faded to the point that it was impossible to determine the patient name, drug name, dose, route, expiration date, or physician ordering the medication. There was one tube of antibiotic ointment in the drawer without a cap. There were multiple prescription bottles containing duplicate medications with different dosages and strengths. It was noted that the family administers all of the CR's medications.

CR #4, start of care March 16, 2019. Upon review of the CR on May 9, 2019, at approximately 12:00 P.M., the dosage of Propranolol (cardiac, beta blocker), Flax Seed Oil (supplement), and Acetaminophen (pain, fever) listed on the medication profile dated March 16, 2019, did not match the dosage listed on the Medication Treatment Record for March, 2019. Four (4) additional medications on the Medication Treatment Record that were not listed on the medication profile, Nystatin Triamcinolone cream (anti-fungal/anti-inflammatory), Hydrocortisone 2.5% cream (anti-inflammatory), Mupirocin 2% ointment (topical antibiotic), and Clindamycin (antibiotic), nor was there any evidence of a physician's order obtained for the additional medications.

CR #7, start of care February 11, 2019. Review of the CR on May 9, 2019, at approximately 1:00 P.M. revealed that the patient was admitted to the hospital on February 20, 2019, and has not received home health services since that date. The CR contained an order to hold services for hospital admission on February 20, 2019. The CR did not contain a discharge order, discharge assessment or discharge summary. The certification period ended April 11, 2019. The medication profile contained a duplicate order for Vitamin C.

An interview with the administrator, alternate administrator and assistant director of nursing trainee on May 10, 2019, at approximately 11:30 A.M. confirmed that registered nurse (RN) failed to complete a timely and/or complete comprehensive assessment and/or review/update of the medication profile prior to the start of the certification period.














Plan of Correction:

CR#2
Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient.
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator and Nursing department to discuss PA DOH deficiencies from 05/14/2019
Skilled Nursing Services policy to be reviewed and updated as needed by Professional Advisory Committee .
The Administrator will schedule training sessions for all Nurses to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning integration of orders. The DON will complete mandatory in-services with the nursing staff to emphasize the need for coordination of care between members of the care team. This communication be placed in the medical record and/or case conference minutes, and will be monitored by the clinical supervisors responsible to ensure that the communication is taking place and being documented., and that if improvement is not noted, this could result in individual counseling, which could result in termination as they continue through the disciplinary process.
Administrator and Don will audit 100% of patient clinical records and determine areas that require improvement in coordination of care and Integration of orders.
RN's coordination/integration of orders process includes, but is not limited to:the assurance of the following:
a. Every patient will be reviewed for coordination of care needs, establishment of care goals, progress and/or barriers reviewed, health status and any continued need for services.
b. Medications and treatments orders are to be reviewed and reconciled as needed during each nursing visit, any discrepancies are to be clarified with physician and orders obtained if needed.
c. Assure communication with all physicians involved in the plan of care.
d. All orders obtained from physician will be added to patient treatment record or medication treatment record, to medication profile and an addendum/update will be made to the plan of treatment. Communications will be put in place for all nurses providing care to patient as well as patient/family regarding changes/updates.
e. All medications in patients home will be reviewed to determine if they are compliant with current medication orders.
f. Any Medication that is not found in current plan of care will be discussed with MD to determine if an order has been made for this medication, needs to be obtained, has been made by another physician or if medication needs to be discarded.
g. Nurses will provide education to Patient/family regarding orders and the need to discard/reorganize all other medications that are not ordered or order/dosages have changed. Nurses are to document patient/family compliance and report to md as needed. Communications with MD are to be placed in patient clinical record.
h. Documentation needs to be in place when family administers all medications to patient or if no medications are administered during the time nurse is providing care.
i. There must be orders for all medications listed in medication treatment record . All medication orders are to be obtained from physician prior to placing in medication treatment orders.
j. Recertification and ROC:
The RN Case Manager is responsible for collaborating with each identified care provider to identify progress and/or barriers to goals and documenting the progress and collaboration in the clinical record.
k. Discharge: The RN Case Manager is responsible for communicating the planned discharge date to the other care providers as well as communicating the patient's
l. Integrate orders from all physicians involved in the plan of care and interventions provided to the patient Integrate services, whether services are provided directly or under arrangement, to assure the identification of pt needs & factors that could affect pt safety & treatment effectiveness & the coordination of care provided by all disciplines.
m. Coordinate care delivery to meet the patient's needs, & involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities.
n. Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education & training provided by the HHA, as appropriate, regarding the care & services identified in the plan of care.
Any patient identified as needing improvement in any of the areas mentioned will be scheduled for care coordination conference as soon as possible. The RN Case Managers will address coordination of care with nurses as a component of their supervisory visits as the RN Case Manager, Visit Nurse ,Patient, Patient Representative (if any) will be available at the patient's place of residence at the time of the supervisory visits to discuss any items listed above as needed, patient family concerns, assess patient/family understanding of care and compliance. will be discussed,
The Administrator ,Director of Nursing and Quality Management designee will review all records monthly for coordination of care and inclusions of case conference for patients receiving care for more than one certification period. This will occur until there is 100%compliance. Then 20% of patient records will be reviewed quarterly during record reviews and quality management meetings.
Responsible: Administrator
Date of Completion 07/13/2019

CR#3
Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient.
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator and Nursing department to discuss PA DOH deficiencies from 05/14/2019
Skilled Nursing Services policy to be reviewed and updated as needed by Professional Advisory Committee .
The Administrator will schedule training sessions for all Nurses to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning integration of orders. The DON will complete mandatory in-services with the nursing staff to emphasize the need for coordination of care between members of the care team. This communication be placed in the medical record and/or case conference minutes, and will be monitored by the clinical supervisors responsible to ensure that the communication is taking place and being documented., and that if improvement is not noted, this could result in individual counseling, which could result in termination as they continue through the disciplinary process.
Administrator and Don will audit 100% of patient clinical records and determine areas that require improvement in coordination of care and Integration of orders.
RN's coordination/integration of orders process includes, but is not limited to:the assurance of the following:
a. Every patient will be reviewed for coordination of care needs, establishment of care goals, progress and/or barriers reviewed, health status and any continued need for services.
b. Medications and treatments orders are to be reviewed and reconciled as needed during each nursing visit, any discrepancies are to be clarified with physician and orders obtained if needed.
c. Assure communication with all physicians involved in the plan of care.
d. All orders obtained from physician will be added to patient treatment record or medication treatment record, to medication profile and an addendum/update will be made to the plan of treatment. Communications will be put in place for all nurses providing care to patient as well as patient/family regarding changes/updates.
e. All medications in patients home will be reviewed to determine if they are compliant with current medication orders.
f. Any Medication that is not found in current plan of care will be discussed with MD to determine if an order has been made for this medication, needs to be obtained, has been made by another physician or if medication needs to be discarded.
g. Nurses will provide education to Patient/family regarding orders and the need to discard/reorganize all other medications that are not ordered or order/dosages have changed. Nurses are to document patient/family compliance and report to md as needed. Communications with MD are to be placed in patient clinical record.
h. Documentation needs to be in place when family administers all medications to patient or if no medications are administered during the time nurse is providing care.
i. There must be orders for all medications listed in medication treatment record . All medication orders are to be obtained from physician prior to placing in medication treatment orders.
j. Recertification and ROC:
The RN Case Manager is responsible for collaborating with each identified care provider to identify progress and/or barriers to goals and documenting the progress and collaboration in the clinical record.
k. Discharge: The RN Case Manager is responsible for communicating the planned discharge date to the other care providers as well as communicating the patient's
l. Integrate orders from all physicians involved in the plan of care and interventions provided to the patient Integrate services, whether services are provided directly or under arrangement, to assure the identification of pt needs & factors that could affect pt safety & treatment effectiveness & the coordination of care provided by all disciplines.
m. Coordinate care delivery to meet the patient's needs, & involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities.
n. Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education & training provided by the HHA, as appropriate, regarding the care & services identified in the plan of care.
Any patient identified as needing improvement in any of the areas mentioned will be scheduled for care coordination conference as soon as possible. The RN Case Managers will address coordination of care with nurses as a component of their supervisory visits as the RN Case Manager, Visit Nurse ,Patient, Patient Representative (if any) will be available at the patient's place of residence at the time of the supervisory visits to discuss any items listed above as needed, patient family concerns, assess patient/family understanding of care and compliance. will be discussed,
The Administrator ,Director of Nursing and Quality Management designee will review all records monthly for coordination of care and inclusions of case conference for patients receiving care for more than one certification period. This will occur until there is 100%compliance. Then 20% of patient records will be reviewed quarterly during record reviews and quality management meetings.
Responsible: Administrator
Date of Completion 07/13/2019

CR#4
Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient.
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator and Nursing department to discuss PA DOH deficiencies from 05/14/2019
Skilled Nursing Services policy to be reviewed and updated as needed by Professional Advisory Committee .
The Administrator will schedule training sessions for all Nurses to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning integration of orders. The DON will complete mandatory in-services with the nursing staff to emphasize the need for coordination of care between members of the care team. This communication be placed in the medical record and/or case conference minutes, and will be monitored by the clinical supervisors responsible to ensure that the communication is taking place and being documented., and that if improvement is not noted, this could result in individual counseling, which could result in termination as they continue through the disciplinary process.
Administrator and Don will audit 100% of patient clinical records and determine areas that require improvement in coordination of care and Integration of orders.
RN's coordination/integration of orders process includes, but is not limited to:the assurance of the following:
a. Every patient will be reviewed for coordination of care needs, establishment of care goals, progress and/or barriers reviewed, health status and any continued need for services.
b. Medications and treatments orders are to be reviewed and reconciled as needed during each nursing visit, any discrepancies are to be clarified with physician and orders obtained if needed.
c. Assure communication with all physicians involved in the plan of care.
d. All orders obtained from physician will be added to patient treatment record or medication treatment record, to medication profile and an addendum/update will be made to the plan of treatment. Communications will be put in place for all nurses providing care to patient as well as patient/family regarding changes/updates.
e. All medications in patients home will be reviewed to determine if they are compliant with current medication orders.
f. Any Medication that is not found in current plan of care will be discussed with MD to determine if an order has been made for this medication, needs to be obtained, has been made by another physician or if medication needs to be discarded.
g. Nurses will provide education to Patient/family regarding orders and the need to discard/reorganize all other medications that are not ordered or order/dosages have changed. Nurses are to document patient/family compliance and report to md as needed. Communications with MD are to be placed in patient clinical record.
h. Documentation needs to be in place when family administers all medications to patient or if no medications are administered during the time nurse is providing care.
i. There must be orders for all medications listed in medication treatment record . All medication orders are to be obtained from physician prior to placing in medication treatment orders.
j. Recertification and ROC:
The RN Case Manager is responsible for collaborating with each identified care provider to identify progress and/or barriers to goals and documenting the progress and collaboration in the clinical record.
k. Discharge: The RN Case Manager is responsible for communicating the planned discharge date to the other care providers as well as communicating the patient's
l. Integrate orders from all physicians involved in the plan of care and interventions provided to the patient Integrate services, whether services are provided directly or under arrangement, to assure the identification of pt needs & factors that could affect pt safety & treatment effectiveness & the coordination of care provided by all disciplines.
m. Coordinate care delivery to meet the patient's needs, & involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities.
n. Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education & training provided by the HHA, as appropriate, regarding the care & services identified in the plan of care.
Any patient identified as needing improvement in any of the areas mentioned will be scheduled for care coordination conference as soon as possible. The RN Case Managers will address coordination of care with nurses as a component of their supervisory visits as the RN Case Manager, Visit Nurse ,Patient, Patient Representative (if any) will be available at the patient's place of residence at the time of the supervisory visits to discuss any items listed above as needed, patient family concerns, assess patient/family understanding of care and compliance. will be discussed,
The Administrator ,Director of Nursing and Quality Management designee will review all records monthly for coordination of care and inclusions of case conference for patients receiving care for more than one certification period. This will occur until there is 100%compliance. Then 20% of patient records will be reviewed quarterly during record reviews and quality management meetings.
Responsible: Administrator
Date of Completion 07/13/2019

CR#7
Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient.
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator and Nursing department to discuss PA DOH deficiencies from 05/14/2019
Skilled Nursing Services policy to be reviewed and updated as needed by Professional Advisory Committee .
The Administrator will schedule training sessions for all Nurses to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning integration of orders. The DON will complete mandatory in-services with the nursing staff to emphasize the need for coordination of care between members of the care team. This communication be placed in the medical record and/or case conference minutes, and will be monitored by the clinical supervisors responsible to ensure that the communication is taking place and being documented., and that if improvement is not noted, this could result in individual counseling, which could result in termination as they continue through the disciplinary process.
Administrator and Don will audit 100% of patient clinical records and determine areas that require improvement in coordination of care and Integration of orders.
RN's coordination/integration of orders process includes, but is not limited to:the assurance of the following:
a. Every patient will be reviewed for coordination of care needs, establishment of care goals, progress and/or barriers reviewed, health status and any continued need for services.
b. Medications and treatments orders are to be reviewed and reconciled as needed during each nursing visit, any discrepancies are to be clarified with physician and orders obtained if needed.
c. Assure communication with all physicians involved in the plan of care.
d. All orders obtained from physician will be added to patient treatment record or medication treatment record, to medication profile and an addendum/update will be made to the plan of treatment. Communications will be put in place for all nurses providing care to patient as well as patient/family regarding changes/updates.
e. All medications in patients home will be reviewed to determine if they are compliant with current medication orders.
f. Any Medication that is not found in current plan of care will be discussed with MD to determine if an order has been made for this medication, needs to be obtained, has been made by another physician or if medication needs to be discarded.
g. Nurses will provide education to Patient/family regarding orders and the need to discard/reorganize all other medications that are not ordered or order/dosages have changed. Nurses are to document patient/family compliance and report to md as needed. Communications with MD are to be placed in patient clinical record.
h. Documentation needs to be in place when family administers all medications to patient or if no medications are administered during the time nurse is providing care.
i. There must be orders for all medications listed in medication treatment record . All medication orders are to be obtained from physician prior to placing in medication treatment orders.
j. Recertification and ROC:
The RN Case Manager is responsible for collaborating with each identified care provider to identify progress and/or barriers to goals and documenting the progress and collaboration in the clinical record.
k. Discharge: The RN Case Manager is responsible for communicating the planned discharge date to the other care providers as well as communicating the patient's
l. Integrate orders from all physicians involved in the plan of care and interventions provided to the patient Integrate services, whether services are provided directly or under arrangement, to assure the identification of pt needs & factors that could affect pt safety & treatment effectiveness & the coordination of care provided by all disciplines.
m. Coordinate care delivery to meet the patient's needs, & involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities.
n. Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education & training provided by the HHA, as appropriate, regarding the care & services identified in the plan of care.
Any patient identified as needing improvement in any of the areas mentioned will be scheduled for care coordination conference as soon as possible. The RN Case Managers will address coordination of care with nurses as a component of their supervisory visits as the RN Case Manager, Visit Nurse ,Patient, Patient Representative (if any) will be available at the patient's place of residence at the time of the supervisory visits to discuss any items listed above as needed, patient family concerns, assess patient/family understanding of care and compliance. will be discussed,
The Administrator ,Director of Nursing and Quality Management designee will review all records monthly for coordination of care and inclusions of case conference for patients receiving care for more than one certification period. This will occur until there is 100%compliance. Then 20% of patient records will be reviewed quarterly during record reviews and quality management meetings.
Responsible: Administrator
Date of Completion 07/13/2019


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 agency policy, personnel files (PF), and interview with agency staff, it was determined the agency failed to ensure personnel policies were followed pertaining to qualifications and performance evaluations for six (6) of eleven (11) PF reviewed. (PF# 2, 3, 7. 8, 9, and 11), background checks for eight (8), of eleven (11) PF reviewed. (PF #2, 3, 5, 6, 7, 8, 9, and 10), and screening of employees upon hire and annually for mycobacterium tuberculosis for three (3) of eleven (11) PF reviewed. (PF # 2, 5, and 9)

Findings Included:

Review of agency policy #HR-12.0 "Core Competency Skills/Employee Performance Criteria" on May 10, 2019, at approximately 10:30 A.M. revealed:
"Procedure: Core Competency Skills: 1. Elite Home Health Care will define the mandatory core competency skills for each discipline based upon the nature of their job responsibilities and complexity of care required. Discipline specific Competency Skill Assessment Checklists (copies attached) will be reviewed with new personnel during their orientation based on their specific disciplines... Employee Performance Criteria: 1. Agency personnel will demonstrate proficiency in the performance criteria/skills during their orientation period which must be demonstrated at three (3) months and at least, annually thereafter as part of the annual performance evaluation process...."

Review of the agency Policy # HR-7.0 "Employee Background Checks" on May 10, 2019, at approximately 10:30 A.M. revealed the following: "Procedure: Guidelines: 1. Elite Home Health Care conducts background checks on all job candidates post-offer (contingency offer). The type of information that is collected by the agency is based on the services that are provided to patients and families as well as the job function that the candidate will perform at the agency. This process occurs in order to verify the accuracy of the information provided by the candidate and determines his/her suitability for employment. All background checks are documented in the employee's personnel file. The background check screening includes, but is not limited to: A. Pennsylvania Criminal Background Check (upon hire), B. FBI Background Check (if PA resident less than 2 years), C. Childline Clearance (for clinical staff with significant likelihood of regular contact with children... 2. Background checks are required for all new hires. This includes all full-time, part-time and temporary employees. The background check must be completed and results verified before any employee begins work. At no time should an employee begin work until the results of the background check have been verified...."

A review of agency policy # HR-5.0 "Screening Employees for Tuberculosis" on May 10, 2019, at approximately 10:30 A.M. revealed the following:
"Procedure: 1. New Employees: D. Two-step skin testing will be done when there is not a documented PPD skin test within the past 12 months.... 4. Annual Verification: A. All employees, office staff or contractors who have direct consumer contact must update their screening documentation no less than every 12 months. For purposes of the Department of Health licensing review, "screening" can be a series of questions to determine if the employee has had an exposure to active TB or their level of risk has changed... B. The 12-month period shall run from the date of the last evaluation..."

A review of PF conducted on May 10, 2019, at approximately 9:00 A.M. revealed the following:

PF #2, date of hire 2005, did not contain documentation of annual performance evaluations.
The Pennsylvania State Police Clearance contained in the PF was dated April 21, 2017. There was no evidence of a Pennsylvania State Police Clearance conducted upon hire. The FBI background check contained in the PF was dated August 9, 2018. There was no evidence of a FBI background check conducted upon hire. There was no documentation of a Childline Clearance conducted upon hire.
A chest x-ray was documented on May 2, 2017. A TST was documented on June 14, 2018, but did not contain a result of the test.

PF #3, date of hire August 10, 2017, did not contain documentation of annual performance evaluations. The Pennsylvania State Police Clearance contained in the PF was dated February 6, 2018. The Childline Clearance contained in the PF was dated November 20, 2015. There was no evidence of a Pennsylvania State Police Clearance or a Childline Clearance conducted upon hire.

PF #5, date of hire August 11, 2017. The Childline Clearance in the PF was dated October 18, 2018, fourteen (14) months after the date of hire. An initial TST was documented on July 28, 2017. There was no documentation of a second step TST.

PF #6, date of hire March 1, 2019. Documentation in the PF shows only one year of residency in Pennsylvania. There is no evidence of a FBI background check completed upon hire.

PF #7, date of hire October 27, 2017, did not contain documentation of an annual competency evaluation for 2018. The FBI background check contained in the PF was dated May 29, 2014. There was no documentation of length of Pennsylvania residency in the PF. The Childline Clearance in the PF was dated November 21, 2018, seven (7) months after the date of hire. There was no evidence of a FBI background check or Childline Clearance conducted upon hire.

PF #8, date of hire January 8, 2018, did not contain documentation of a three month or an annual performance evaluation. The Pennsylvania State Police Clearance contained in the PF was dated March 13, 2018 (two months after the date of hire). There was no documentation of length of Pennsylvania residency in the PF. There was no evidence of a FBI background check or a Childline Clearance conducted upon hire.

PF #9, date of hire January 25, 2018, did not contain documentation of a three month or an annual performance evaluation. The Childline Clearance contained in the PF was dated April 11, 2019 (2 1/2 months after the date of hire). A previous two-step TST was completed on October 2, 2017, and October 5, 2017. An annual TST was completed on April 9, 2019, six months past the due date.

PF #10, date of hire January 22, 2018. There was no documentation of length of Pennsylvania residency in the PF. The FBI background check contained in the PF was dated November 1, 2018 (9 months after the date of hire). The Childline Clearance contained in the PF was dated October 3, 2018 (8 months after the date of hire). There was no evidence of a FBI background check or Childline Clearance conducted upon hire.

PF #11, date of hire April 6, 2019, did not contain documentation of an initial competency test or skills evaluation upon hire.

An interview with the administrator, alternate administrator, assistant director of nursing trainee, and operations manager on May 10, 2019, at approximately 11:30 A.M. confirmed the above items were not present in the personnel files.



















Plan of Correction:

A (PF#2)
a. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Core Competency Skills/Employee Performance Criteria policy to be reviewed by Professional Advisory Committee
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Core Competency Skills/Employee Performance Criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming Core Competency Skill assessments were performed on all employee and contractors according to their specific disciplines during orientation process, at three months (along with 90 day performance evaluation) and at least annually (along with annual performance evaluation).
If documentation regarding competencies is not present for any or all of these periods, HR will document the name of the person, their specific discipline, the skills competency missing and send it to Administrator to schedule Skills competency assessments and evaluations (if needed). In the case that an employee or contractor is unable or unwilling to schedule a competency appointment, a qualified replacement will be put in their place until such employee/contractor completes the required competency and/or evaluation.

Upon Hire, HR personnel will schedule initial skill competency assessment and place date on " Employee Documentation" spreadsheet as well as the projected dates of the 3 month and annual skills competency assessment and performance evaluations. Employees not documented on spreadsheet as having initial skills assessments will be marked as " not ready to start". During the month prior to next skills competency assessment, HR will establish communications with employee/contractor to schedule and confirm actual date of next skills competency assessment and discussion of performance evaluation. Employee performance evaluations will be tracked for the same date of skills competency assessments.
Employee/Contractor files will be audited quarterly during Quality Management Meetings to document compliance. Proper actions will be taken upon review of audit results.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019


A (PF#3)
a. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Core Competency Skills/Employee Performance Criteria policy to be reviewed by Professional Advisory Committee
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Core Competency Skills/Employee Performance Criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming Core Competency Skill assessments were performed on all employee and contractors according to their specific disciplines during orientation process, at three months (along with 90 day performance evaluation) and at least annually (along with annual performance evaluation).
If documentation regarding competencies is not present for any or all of these periods, HR will document the name of the person, their specific discipline, the skills competency missing and send it to Administrator to schedule Skills competency assessments and evaluations (if needed). In the case that an employee or contractor is unable or unwilling to schedule a competency appointment, a qualified replacement will be put in their place until such employee/contractor completes the required competency and/or evaluation.

Upon Hire, HR personnel will schedule initial skill competency assessment and place date on " Employee Documentation" spreadsheet as well as the projected dates of the 3 month and annual skills competency assessment and performance evaluations. Employees not documented on spreadsheet as having initial skills assessments will be marked as " not ready to start". During the month prior to next skills competency assessment, HR will establish communications with employee/contractor to schedule and confirm actual date of next skills competency assessment and discussion of performance evaluation. Employee performance evaluations will be tracked for the same date of skills competency assessments.
Employee/Contractor files will be audited quarterly during Quality Management Meetings to document compliance. Proper actions will be taken upon review of audit results.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

A (PF#7)
a. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Core Competency Skills/Employee Performance Criteria policy to be reviewed by Professional Advisory Committee
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Core Competency Skills/Employee Performance Criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming Core Competency Skill assessments were performed on all employee and contractors according to their specific disciplines during orientation process, at three months (along with 90 day performance evaluation) and at least annually (along with annual performance evaluation).
If documentation regarding competencies is not present for any or all of these periods, HR will document the name of the person, their specific discipline, the skills competency missing and send it to Administrator to schedule Skills competency assessments and evaluations (if needed). In the case that an employee or contractor is unable or unwilling to schedule a competency appointment, a qualified replacement will be put in their place until such employee/contractor completes the required competency and/or evaluation.

Upon Hire, HR personnel will schedule initial skill competency assessment and place date on " Employee Documentation" spreadsheet as well as the projected dates of the 3 month and annual skills competency assessment and performance evaluations. Employees not documented on spreadsheet as having initial skills assessments will be marked as " not ready to start". During the month prior to next skills competency assessment, HR will establish communications with employee/contractor to schedule and confirm actual date of next skills competency assessment and discussion of performance evaluation. Employee performance evaluations will be tracked for the same date of skills competency assessments.
Employee/Contractor files will be audited quarterly during Quality Management Meetings to document compliance. Proper actions will be taken upon review of audit results.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

A (PF#8)
a. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Core Competency Skills/Employee Performance Criteria policy to be reviewed by Professional Advisory Committee
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Core Competency Skills/Employee Performance Criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming Core Competency Skill assessments were performed on all employee and contractors according to their specific disciplines during orientation process, at three months (along with 90 day performance evaluation) and at least annually (along with annual performance evaluation).
If documentation regarding competencies is not present for any or all of these periods, HR will document the name of the person, their specific discipline, the skills competency missing and send it to Administrator to schedule Skills competency assessments and evaluations (if needed). In the case that an employee or contractor is unable or unwilling to schedule a competency appointment, a qualified replacement will be put in their place until such employee/contractor completes the required competency and/or evaluation.

Upon Hire, HR personnel will schedule initial skill competency assessment and place date on " Employee Documentation" spreadsheet as well as the projected dates of the 3 month and annual skills competency assessment and performance evaluations. Employees not documented on spreadsheet as having initial skills assessments will be marked as " not ready to start". During the month prior to next skills competency assessment, HR will establish communications with employee/contractor to schedule and confirm actual date of next skills competency assessment and discussion of performance evaluation. Employee performance evaluations will be tracked for the same date of skills competency assessments.
Employee/Contractor files will be audited quarterly during Quality Management Meetings to document compliance. Proper actions will be taken upon review of audit results.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

A (PF#9)
a. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Core Competency Skills/Employee Performance Criteria policy to be reviewed by Professional Advisory Committee
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Core Competency Skills/Employee Performance Criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming Core Competency Skill assessments were performed on all employee and contractors according to their specific disciplines during orientation process, at three months (along with 90 day performance evaluation) and at least annually (along with annual performance evaluation).
If documentation regarding competencies is not present for any or all of these periods, HR will document the name of the person, their specific discipline, the skills competency missing and send it to Administrator to schedule Skills competency assessments and evaluations (if needed). In the case that an employee or contractor is unable or unwilling to schedule a competency appointment, a qualified replacement will be put in their place until such employee/contractor completes the required competency and/or evaluation.

Upon Hire, HR personnel will schedule initial skill competency assessment and place date on " Employee Documentation" spreadsheet as well as the projected dates of the 3 month and annual skills competency assessment and performance evaluations. Employees not documented on spreadsheet as having initial skills assessments will be marked as " not ready to start". During the month prior to next skills competency assessment, HR will establish communications with employee/contractor to schedule and confirm actual date of next skills competency assessment and discussion of performance evaluation. Employee performance evaluations will be tracked for the same date of skills competency assessments.
Employee/Contractor files will be audited quarterly during Quality Management Meetings to document compliance. Proper actions will be taken upon review of audit results.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

A (PF#11)
a. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Core Competency Skills/Employee Performance Criteria policy to be reviewed by Professional Advisory Committee
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Core Competency Skills/Employee Performance Criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming Core Competency Skill assessments were performed on all employee and contractors according to their specific disciplines during orientation process, at three months (along with 90 day performance evaluation) and at least annually (along with annual performance evaluation).
If documentation regarding competencies is not present for any or all of these periods, HR will document the name of the person, their specific discipline, the skills competency missing and send it to Administrator to schedule Skills competency assessments and evaluations (if needed). In the case that an employee or contractor is unable or unwilling to schedule a competency appointment, a qualified replacement will be put in their place until such employee/contractor completes the required competency and/or evaluation.

Upon Hire, HR personnel will schedule initial skill competency assessment and place date on " Employee Documentation" spreadsheet as well as the projected dates of the 3 month and annual skills competency assessment and performance evaluations. Employees not documented on spreadsheet as having initial skills assessments will be marked as " not ready to start". During the month prior to next skills competency assessment, HR will establish communications with employee/contractor to schedule and confirm actual date of next skills competency assessment and discussion of performance evaluation. Employee performance evaluations will be tracked for the same date of skills competency assessments.
Employee/Contractor files will be audited quarterly during Quality Management Meetings to document compliance. Proper actions will be taken upon review of audit results.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

B (PF#2)
b. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
a. Employee Background Checks policy to be reviewed and updated as needed by Professional Advisory Committee and HR department.
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Employee Background Checks criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming background checks were performed on all employee and contractors upon hire.
If documentation regarding background checks is not present for any employee, HR will obtain a PA criminal background check and document results. Employees working with children will apply for child abuse clearances, copies of Childline applications will be placed in their file and employee be replaced with qualified personnel until results are received. Fingerprint clearances will be obtained for all employees that do not provide proof of residing in PA during the last 2 years.

All new perspective employees will not be permitted to start working with children until Childline clearances are received. All employees with "pending' PA record results or FBI fingerprint results are to be directly supervised until results are obtained for a period no longer than 90 days.
Tracking system will be created for dates in which all of the background documents are due for re-checking.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

B (PF#3)

b. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
a. Employee Background Checks policy to be reviewed and updated as needed by Professional Advisory Committee and HR department.
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Employee Background Checks criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming background checks were performed on all employee and contractors upon hire.
If documentation regarding background checks is not present for any employee, HR will obtain a PA criminal background check and document results. Employees working with children will apply for child abuse clearances, copies of Childline applications will be placed in their file and employee be replaced with qualified personnel until results are received. Fingerprint clearances will be obtained for all employees that do not provide proof of residing in PA during the last 2 years.

All new perspective employees will not be permitted to start working with children until Childline clearances are received. All employees with "pending' PA record results or FBI fingerprint results are to be directly supervised until results are obtained for a period no longer than 90 days.
Tracking system will be created for dates in which all of the background documents are due for re-checking.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

B (PF#5)

b. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
a. Employee Background Checks policy to be reviewed and updated as needed by Professional Advisory Committee and HR department.
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Employee Background Checks criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming background checks were performed on all employee and contractors upon hire.
If documentation regarding background checks is not present for any employee, HR will obtain a PA criminal background check and document results. Employees working with children will apply for child abuse clearances, copies of Childline applications will be placed in their file and employee be replaced with qualified personnel until results are received. Fingerprint clearances will be obtained for all employees that do not provide proof of residing in PA during the last 2 years.

All new perspective employees will not be permitted to start working with children until Childline clearances are received. All employees with "pending' PA record results or FBI fingerprint results are to be directly supervised until results are obtained for a period no longer than 90 days.
Tracking system will be created for dates in which all of the background documents are due for re-checking.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

B (PF#6)

b. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
a. Employee Background Checks policy to be reviewed and updated as needed by Professional Advisory Committee and HR department.
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Employee Background Checks criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming background checks were performed on all employee and contractors upon hire.
If documentation regarding background checks is not present for any employee, HR will obtain a PA criminal background check and document results. Employees working with children will apply for child abuse clearances, copies of Childline applications will be placed in their file and employee be replaced with qualified personnel until results are received. Fingerprint clearances will be obtained for all employees that do not provide proof of residing in PA during the last 2 years.

All new perspective employees will not be permitted to start working with children until Childline clearances are received. All employees with "pending' PA record results or FBI fingerprint results are to be directly supervised until results are obtained for a period no longer than 90 days.
Tracking system will be created for dates in which all of the background documents are due for re-checking.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

B (PF#7)

b. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
a. Employee Background Checks policy to be reviewed and updated as needed by Professional Advisory Committee and HR department.
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Employee Background Checks criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming background checks were performed on all employee and contractors upon hire.
If documentation regarding background checks is not present for any employee, HR will obtain a PA criminal background check and document results. Employees working with children will apply for child abuse clearances, copies of Childline applications will be placed in their file and employee be replaced with qualified personnel until results are received. Fingerprint clearances will be obtained for all employees that do not provide proof of residing in PA during the last 2 years.

All new perspective employees will not be permitted to start working with children until Childline clearances are received. All employees with "pending' PA record results or FBI fingerprint results are to be directly supervised until results are obtained for a period no longer than 90 days.
Tracking system will be created for dates in which all of the background documents are due for re-checking.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

B (PF#8)

b. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
a. Employee Background Checks policy to be reviewed and updated as needed by Professional Advisory Committee and HR department.
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Employee Background Checks criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming background checks were performed on all employee and contractors upon hire.
If documentation regarding background checks is not present for any employee, HR will obtain a PA criminal background check and document results. Employees working with children will apply for child abuse clearances, copies of Childline applications will be placed in their file and employee be replaced with qualified personnel until results are received. Fingerprint clearances will be obtained for all employees that do not provide proof of residing in PA during the last 2 years.

All new perspective employees will not be permitted to start working with children until Childline clearances are received. All employees with "pending' PA record results or FBI fingerprint results are to be directly supervised until results are obtained for a period no longer than 90 days.
Tracking system will be created for dates in which all of the background documents are due for re-checking.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

B (PF#9)

b. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
a. Employee Background Checks policy to be reviewed and updated as needed by Professional Advisory Committee and HR department.
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Employee Background Checks criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming background checks were performed on all employee and contractors upon hire.
If documentation regarding background checks is not present for any employee, HR will obtain a PA criminal background check and document results. Employees working with children will apply for child abuse clearances, copies of Childline applications will be placed in their file and employee be replaced with qualified personnel until results are received. Fingerprint clearances will be obtained for all employees that do not provide proof of residing in PA during the last 2 years.

All new perspective employees will not be permitted to start working with children until Childline clearances are received. All employees with "pending' PA record results or FBI fingerprint results are to be directly supervised until results are obtained for a period no longer than 90 days.
Tracking system will be created for dates in which all of the background documents are due for re-checking.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

B (PF#10)

b. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
a. Employee Background Checks policy to be reviewed and updated as needed by Professional Advisory Committee and HR department.
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Employee Background Checks criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming background checks were performed on all employee and contractors upon hire.
If documentation regarding background checks is not present for any employee, HR will obtain a PA criminal background check and document results. Employees working with children will apply for child abuse clearances, copies of Childline applications will be placed in their file and employee be replaced with qualified personnel until results are received. Fingerprint clearances will be obtained for all employees that do not provide proof of residing in PA during the last 2 years.

All new perspective employees will not be permitted to start working with children until Childline clearances are received. All employees with "pending' PA record results or FBI fingerprint results are to be directly supervised until results are obtained for a period no longer than 90 days.
Tracking system will be created for dates in which all of the background documents are due for re-checking.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

C (PF#2)
C. Employee" Screening Employees For Tuberculosis" policy to be reviewed and updated as needed by Professional Advisory Committee. HR personnel are to be re-educated on the content of this policy.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming PPD tests were performed as per policy (2 step upon hire and 1 step yearly thereafter)
If documentation regarding PPD testing as per policy is not present for any or all of these periods, HR will notify employee of need for proof of PPD testing results document the name of the persons who are non compliant and send it to DON and Administrator . In the case that an employee or contractor is unable or unwilling to schedule PPD testing, a qualified replacement will be put in their place until such employee/contractor completes the required testing.

In order to prevent recurrence, HR will document every new hires as "incomplete" when Proof of PPD testing (2 step) and notify DON of their inability to start working. All employees will be place in a tracking spread sheet containing the dated in which further documentation is due. DON, Scheduling and Administration will have access to this information.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

C (PF#5)

C. Employee" Screening Employees For Tuberculosis" policy to be reviewed and updated as needed by Professional Advisory Committee. HR personnel are to be re-educated on the content of this policy.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming PPD tests were performed as per policy (2 step upon hire and 1 step yearly thereafter)
If documentation regarding PPD testing as per policy is not present for any or all of these periods, HR will notify employee of need for proof of PPD testing results document the name of the persons who are non compliant and send it to DON and Administrator . In the case that an employee or contractor is unable or unwilling to schedule PPD testing, a qualified replacement will be put in their place until such employee/contractor completes the required testing.

In order to prevent recurrence, HR will document every new hires as "incomplete" when Proof of PPD testing (2 step) and notify DON of their inability to start working. All employees will be place in a tracking spread sheet containing the dated in which further documentation is due. DON, Scheduling and Administration will have access to this information.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

C (PF#9)

C. Employee" Screening Employees For Tuberculosis" policy to be reviewed and updated as needed by Professional Advisory Committee. HR personnel are to be re-educated on the content of this policy.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming PPD tests were performed as per policy (2 step upon hire and 1 step yearly thereafter)
If documentation regarding PPD testing as per policy is not present for any or all of these periods, HR will notify employee of need for proof of PPD testing results document the name of the persons who are non compliant and send it to DON and Administrator . In the case that an employee or contractor is unable or unwilling to schedule PPD testing, a qualified replacement will be put in their place until such employee/contractor completes the required testing.

In order to prevent recurrence, HR will document every new hires as "incomplete" when Proof of PPD testing (2 step) and notify DON of their inability to start working. All employees will be place in a tracking spread sheet containing the dated in which further documentation is due. DON, Scheduling and Administration will have access to this information.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019




484.110(a)(6)(i-iii) ELEMENT
Discharge and transfer summaries

Name - Component - 00
(i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or
(ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or
(iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer.

Observations:


Based on a review of clinical records (CRs), agency policy, and an interview with the administrator, alternate administrator, operations manager, and assistant nursing supervisor trainee, the agency failed to provide documentation that a discharge summary was sent to the primary care physician within five (5) days of discharge for two (2) of two (2) discharged CRs reviewed (CR# 6 and 7).

Findings included:

Review of agency policy C# 10.0 titled "Discharge from Services" on May 10, 2019, at approximately 10:30 A.M. states, "Procedure: 2. Patients may be discharged from Elite Home Health Care for the following reasons: C. ii. Hospitalization (Medicare patient will be discharged at end of 60-day episode)... 3. Process for Routine Discharge: B. A verbal order is obtained from the physician in order to notify him/her each time a discipline/service is discharged from the patient's plan of care/treatment... F. OASIS discharge assessment will be completed and submitted within forty-eight (48) hours.

A review of CR conducted on May 10, 2019, from approximately 9:00 A.M. to 2:30 P.M. revealed the following:

CR#6, start of care August 21, 2017. Patient was admitted to the hospital on April 15, 2019. The patient remains hospitalized as of May 10, 2019. The patient was identified by the operations manager on May 8, 2019, at approximately 10:00 A.M. as discharged. There was no documentation to show a discharge order or discharge summary was sent to the primary care physician upon discharge. The patient is under the age of eighteen (18) and did not require an OASIS assessment.

CR#7, start of care February 11, 2019. Patient was admitted to the hospital on February 22, 2019. The certification period ended on April 11, 2019. The patient remains in an inpatient facility as of May 10, 2019. There was no documentation to show a discharge order or discharge summary was sent to the primary care physician upon discharge. There was no OASIS discharge assessment completed.

An interview with the administrator, alternate administrator, operations manager, and assistant director of nursing trainee on May 10, 2019, at approximately 11:30 A.M. confirmed the above findings.




























Plan of Correction:

CR#6
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Discharge from services policy to be reviewed and updated as needed by Professional Advisory Committee. All RN's responsible for patient discharges, assessments and OASIS data collection will be in-serviced on policy, which includes required time frames A completed discharge summary that is sent to the primary care practitioner within 5 business days of the patient's discharge; or A completed transfer summary that is sent within 2 business days of a planned transfer, A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer for patients over the age of 18 receiving skilled services).
DON and ADON will review each discharged patient file to determine if documentation is present, such as: Discharge order and/or discharge summary and confirmation of notification to physician of the discharge from services.
Documentation is to be completed as per policy and sent to physician with documentation regarding reasons this was not completed in the required timeframe placed in patients file.
To prevent future occurrence, On a Monthly basis , all discharged patient files will be reviewed by DON and RN who discharged to determine compliance with time frames for assessment, OASIS transmissions and physician notification of discharges until 100% compliance is noted, then 25% of all discharges will be audited quarterly during quarterly record reviews and quality management meetings to determine compliance. Administrator will review results. Additional actions needed will be determined during Quality Management Meetings.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019


CR#7

Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Discharge from services policy to be reviewed and updated as needed by Professional Advisory Committee. All RN's responsible for patient discharges, assessments and OASIS data collection will be in-serviced on policy, which includes required time frames A completed discharge summary that is sent to the primary care practitioner within 5 business days of the patient's discharge; or A completed transfer summary that is sent within 2 business days of a planned transfer, A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer for patients over the age of 18 receiving skilled services).
DON and ADON will review each discharged patient file to determine if documentation is present, such as: Discharge order and/or discharge summary and confirmation of notification to physician of the discharge from services.
Documentation is to be completed as per policy and sent to physician with documentation regarding reasons this was not completed in the required timeframe placed in patients file.
To prevent future occurrence, On a Monthly basis , all discharged patient files will be reviewed by DON and RN who discharged to determine compliance with time frames for assessment, OASIS transmissions and physician notification of discharges until 100% compliance is noted, then 25% of all discharges will be audited quarterly during quarterly record reviews and quality management meetings to determine compliance. Administrator will review results. Additional actions needed will be determined during Quality Management Meetings.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019


484.115(c) STANDARD
Clinical Manager

Name - Component - 00
Standard: Clinical manager. A person who is a licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker, or a registered nurse.

Observations:

Based on review of agency job descriptions, employee personnel (PF) files, and an interview with the administrator, assistant director of nursing trainee, the alternate administrator, and the operations manager, the governing body and the administrator failed to ensure a qualified registered nurse (RN) was appointed to the position of director of nursing (DON) and assistant director of nursing (ADON).

Findings included:

On May 10, 2019, at approximately 11:00 A.M., review of the agency job description titled "Director of Nursing" revealed the following:
"E. Education and Experience: 2. Experience: a. Minimum three (3) years experience in nursing, with at least tow (2) years in home health or community health nursing required. b. Minimum one (1) year in a supervisory or management position..."

On May 10, 2019, at approximately 11:00 A.M., review of agency job description titled "Assistant Director of Nursing Trainee" revealed the following:
"E. Education and Experience: 2. Experience: a. experience in nursing, with at least two (2) years in home health or community health required..."

A review of personnel files conducted on May 10, 2019, from approximately 9:30 A.M. to 10:30 A.M. revealed the following:

PF #1, Assistant Director of Nursing Trainee: date of hire April 17, 2019. Pennsylvania State RN license documentation revealed the RN license was issued on April 16, 2019. The employee's application notes graduation from Aria Health School of Nursing in 2019. There was no documentation that the Assistant DON trainee met the qualifications for supervising nurse under 28 Pa. Code, Part IV, Health Facilities, and Subpart G. Chapter 601 and agency policy.

PF #4, Director of Nursing: date of hire September 18, 2018, Pennsylvania State Registered Nurse (RN) license documentation revealed the RN license was issued on August 21, 2018. The employee's resume lists graduation from Aria Health School of Nursing on June 25, 2018. There was no documentation that the DON met the qualifications for supervising nurse under 28 Pa. Code, Part IV, Health Facilities, and Subpart G. Chapter 601 and agency policy.

An interview with the administrator, alternate administrator, assistant director of nursing trainee, and director of operations on May 10, 2019, at approximately 11:30 A.M. confirmed the above findings.













Plan of Correction:

CR#1
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Clinical Manager/Director of Nursing and Assistance Director of Nursing and RN Supervisor Job Descriptions ,education and experience requirements to be reviewed and updated as needed by Professional Advisory Committee.
It was decided that Administrator and Co Administrator will assume the positions of DON and ADON until qualified personnel are assigned to these positions.
RN's currently holding these positions will be assigned other qualified RN roles and will be oriented to their Job Description.

To prevent future occurrences, Administrator will cross check Job descriptions with Applicant qualifications before hire.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019


CR#4
Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Clinical Manager/Director of Nursing and Assistance Director of Nursing and RN Supervisor Job Descriptions ,education and experience requirements to be reviewed and updated as needed by Professional Advisory Committee.
It was decided that Administrator and Co Administrator will assume the positions of DON and ADON until qualified personnel are assigned to these positions.
RN's currently holding these positions will be assigned other qualified RN roles and will be oriented to their Job Description.

To prevent future occurrences, Administrator will cross check Job descriptions with Applicant qualifications before hire.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019


Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification survey conducted May 8, 2019, through May 10, 2019, and May 14, 2019, Elite Home Health Care, Inc., 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 unannounced onsite state re-licensure survey conducted May 8, 2019, through May 10, 2019, and May 14, 2019, Elite Home Health Care, Inc. was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health facilities, Subpart G. Chapter 601.








Plan of Correction:




601.3 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 agency policy, personnel files (PF), and interview with agency staff, it was determined the agency failed to ensure personnel policies were followed pertaining to background checks for eight (8), of eleven (11) PF reviewed. (PF #2, 3, 5, 6, 7, 8, 9, and 10), and screening of employees upon hire and annually for mycobacterium tuberculosis for three (3) of eleven (11) PF reviewed. (PF # 2, 5, and 9)

Findings Included:

Review of the agency Policy # HR-7.0 "Employee Background Checks" on May 10, 2019, at approximately 10:30 A.M. revealed the following: "Procedure: Guidelines: 1. Elite Home Health Care conducts background checks on all job candidates post-offer (contingency offer). The type of information that is collected by the agency is based on the services that are provided to patients and families as well as the job function that the candidate will perform at the agency. This process occurs in order to verify the accuracy of the information provided by the candidate and determines his/her suitability for employment. All background checks are documented in the employee's personnel file. The background check screening includes, but is not limited to: A. Pennsylvania Criminal Background Check (upon hire), B. FBI Background Check (if PA resident less than 2 years), C. Childline Clearance (for clinical staff with significant likelihood of regular contact with children... 2. Background checks are required for all new hires. This includes all full-time, part-time and temporary employees. The background check must be completed and results verified before any employee begins work. At no time should an employee begin work until the results of the background check have been verified...."

A review of agency policy # HR-5.0 "Screening Employees for Tuberculosis" on May 10, 2019, at approximately 10:30 A.M. revealed the following:
"Procedure: 1. New Employees: D. Two-step skin testing will be done when there is not a documented PPD skin test within the past 12 months.... 4. Annual Verification: A. All employees, office staff or contractors who have direct consumer contact must update their screening documentation no less than every 12 months. For purposes of the Department of Health licensing review, "screening" can be a series of questions to determine if the employee has had an exposure to active TB or their level of risk has changed... B. The 12-month period shall run from the date of the last evaluation..."

A review of PF conducted on May 10, 2019, at approximately 9:00 A.M. revealed the following:

PF #2, date of hire 2005. The Pennsylvania State Police Clearance contained in the PF was dated April 21, 2017. There was no evidence of a Pennsylvania State Police Clearance conducted upon hire. The FBI background check contained in the PF was dated August 9, 2018. There was no evidence of a FBI background check conducted upon hire. There was no documentation of a Childline Clearance conducted upon hire. A chest x-ray was documented on May 2, 2017. A TST was documented on June 14, 2018, but did not contain a result of the test.

PF #3, date of hire August 10, 2017. The Pennsylvania State Police Clearance contained in the PF was dated February 6, 2018. The Childline Clearance contained in the PF was dated November 20, 2015. There was no evidence of a Pennsylvania State Police Clearance or a Childline Clearance conducted upon hire.

PF #5, date of hire August 11, 2017. The Childline Clearance in the PF was dated October 18, 2018, fourteen (14) months after the date of hire. An initial TST was documented on July 28, 2017. There was no documentation of a second step TST.

PF #6, date of hire March 1, 2019. Documentation in the PF shows only one year of residency in Pennsylvania. There is no evidence of a FBI background check completed upon hire.

PF #7, date of hire October 27, 2017. The FBI background check contained in the PF was dated May 29, 2014. There was no documentation of length of Pennsylvania residency in the PF. The Childline Clearance in the PF was dated November 21, 2018, seven (7) months after the date of hire. There was no evidence of a FBI background check or Childline Clearance conducted upon hire.

PF #8, date of hire January 8, 2018. The Pennsylvania State Police Clearance contained in the PF was dated March 13, 2018 (two months after the date of hire). There was no documentation of length of Pennsylvania residency in the PF. There was no evidence of a FBI background check or a Childline Clearance conducted upon hire.

PF #9, date of hire January 25, 2018. The Childline Clearance contained in the PF was dated April 11, 2019 (2 1/2 months after the date of hire). A previous two-step TST was completed on October 2, 2017, and October 5, 2017. An annual TST was completed on April 9, 2019, six months past the due date.

PF #10, date of hire January 22, 2018. There was no documentation of length of Pennsylvania residency in the PF. The FBI background check contained in the PF was dated November 1, 2018 (9 months after the date of hire). The Childline Clearance contained in the PF was dated October 3, 2018 (8 months after the date of hire). There was no evidence of a FBI background check or Childline Clearance conducted upon hire.

An interview with the administrator, alternate administrator, assistant director of nursing trainee, and operations manager on May 10, 2019, at approximately 11:30 A.M. confirmed the above items were not present in the personnel files.






































Plan of Correction:

A (PF#2)

a. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Employee Background Checks policy to be reviewed and updated as needed by Professional Advisory Committee and HR department.
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Employee Background Checks criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming background checks were performed on all employee and contractors upon hire.
If documentation regarding background checks is not present for any employee, HR will obtain a PA criminal background check and document results. Employees working with children will apply for child abuse clearances, copies of Childline applications will be placed in their file and employee be replaced with qualified personnel until results are received. Fingerprint clearances will be obtained for all employees that do not provide proof of residing in PA during the last 2 years.
All new perspective employees will not be permitted to start working with children until Childline clearances are received. All employees with "pending' PA record results or FBI fingerprint results are to be directly supervised until results are obtained for a period no longer than 90 days.
Tracking system will be created for dates in which all of the background documents are due for re-checking.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

A (PF#3)

a. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Employee Background Checks policy to be reviewed and updated as needed by Professional Advisory Committee and HR department.
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Employee Background Checks criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming background checks were performed on all employee and contractors upon hire.
If documentation regarding background checks is not present for any employee, HR will obtain a PA criminal background check and document results. Employees working with children will apply for child abuse clearances, copies of Childline applications will be placed in their file and employee be replaced with qualified personnel until results are received. Fingerprint clearances will be obtained for all employees that do not provide proof of residing in PA during the last 2 years.
All new perspective employees will not be permitted to start working with children until Childline clearances are received. All employees with "pending' PA record results or FBI fingerprint results are to be directly supervised until results are obtained for a period no longer than 90 days.
Tracking system will be created for dates in which all of the background documents are due for re-checking.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

A (PF#5)

a. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Employee Background Checks policy to be reviewed and updated as needed by Professional Advisory Committee and HR department.
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Employee Background Checks criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming background checks were performed on all employee and contractors upon hire.
If documentation regarding background checks is not present for any employee, HR will obtain a PA criminal background check and document results. Employees working with children will apply for child abuse clearances, copies of Childline applications will be placed in their file and employee be replaced with qualified personnel until results are received. Fingerprint clearances will be obtained for all employees that do not provide proof of residing in PA during the last 2 years.
All new perspective employees will not be permitted to start working with children until Childline clearances are received. All employees with "pending' PA record results or FBI fingerprint results are to be directly supervised until results are obtained for a period no longer than 90 days.
Tracking system will be created for dates in which all of the background documents are due for re-checking.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

A (PF#6)

a. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Employee Background Checks policy to be reviewed and updated as needed by Professional Advisory Committee and HR department.
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Employee Background Checks criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming background checks were performed on all employee and contractors upon hire.
If documentation regarding background checks is not present for any employee, HR will obtain a PA criminal background check and document results. Employees working with children will apply for child abuse clearances, copies of Childline applications will be placed in their file and employee be replaced with qualified personnel until results are received. Fingerprint clearances will be obtained for all employees that do not provide proof of residing in PA during the last 2 years.
All new perspective employees will not be permitted to start working with children until Childline clearances are received. All employees with "pending' PA record results or FBI fingerprint results are to be directly supervised until results are obtained for a period no longer than 90 days.
Tracking system will be created for dates in which all of the background documents are due for re-checking.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

A (PF#7)

a. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Employee Background Checks policy to be reviewed and updated as needed by Professional Advisory Committee and HR department.
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Employee Background Checks criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming background checks were performed on all employee and contractors upon hire.
If documentation regarding background checks is not present for any employee, HR will obtain a PA criminal background check and document results. Employees working with children will apply for child abuse clearances, copies of Childline applications will be placed in their file and employee be replaced with qualified personnel until results are received. Fingerprint clearances will be obtained for all employees that do not provide proof of residing in PA during the last 2 years.
All new perspective employees will not be permitted to start working with children until Childline clearances are received. All employees with "pending' PA record results or FBI fingerprint results are to be directly supervised until results are obtained for a period no longer than 90 days.
Tracking system will be created for dates in which all of the background documents are due for re-checking.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

A (PF#8)

a. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Employee Background Checks policy to be reviewed and updated as needed by Professional Advisory Committee and HR department.
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Employee Background Checks criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming background checks were performed on all employee and contractors upon hire.
If documentation regarding background checks is not present for any employee, HR will obtain a PA criminal background check and document results. Employees working with children will apply for child abuse clearances, copies of Childline applications will be placed in their file and employee be replaced with qualified personnel until results are received. Fingerprint clearances will be obtained for all employees that do not provide proof of residing in PA during the last 2 years.
All new perspective employees will not be permitted to start working with children until Childline clearances are received. All employees with "pending' PA record results or FBI fingerprint results are to be directly supervised until results are obtained for a period no longer than 90 days.
Tracking system will be created for dates in which all of the background documents are due for re-checking.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

A (PF#9)

a. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Employee Background Checks policy to be reviewed and updated as needed by Professional Advisory Committee and HR department.
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Employee Background Checks criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming background checks were performed on all employee and contractors upon hire.
If documentation regarding background checks is not present for any employee, HR will obtain a PA criminal background check and document results. Employees working with children will apply for child abuse clearances, copies of Childline applications will be placed in their file and employee be replaced with qualified personnel until results are received. Fingerprint clearances will be obtained for all employees that do not provide proof of residing in PA during the last 2 years.
All new perspective employees will not be permitted to start working with children until Childline clearances are received. All employees with "pending' PA record results or FBI fingerprint results are to be directly supervised until results are obtained for a period no longer than 90 days.
Tracking system will be created for dates in which all of the background documents are due for re-checking.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

A (PF#10)

a. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Employee Background Checks policy to be reviewed and updated as needed by Professional Advisory Committee and HR department.
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Employee Background Checks criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming background checks were performed on all employee and contractors upon hire.
If documentation regarding background checks is not present for any employee, HR will obtain a PA criminal background check and document results. Employees working with children will apply for child abuse clearances, copies of Childline applications will be placed in their file and employee be replaced with qualified personnel until results are received. Fingerprint clearances will be obtained for all employees that do not provide proof of residing in PA during the last 2 years.
All new perspective employees will not be permitted to start working with children until Childline clearances are received. All employees with "pending' PA record results or FBI fingerprint results are to be directly supervised until results are obtained for a period no longer than 90 days.
Tracking system will be created for dates in which all of the background documents are due for re-checking.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

B (PF#2)

b. Employee" Screening Employees For Tuberculosis" policy to be reviewed and updated as needed by Professional Advisory Committee. HR personnel are to be re-educated on the content of this policy.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming PPD tests were performed as per policy (2 step upon hire and 1 step yearly thereafter)
If documentation regarding PPD testing as per policy is not present for any or all of these periods, HR will notify employee of need for proof of PPD testing results document the name of the persons who are non compliant and send it to DON and Administrator . In the case that an employee or contractor is unable or unwilling to schedule PPD testing, a qualified replacement will be put in their place until such employee/contractor completes the required testing.
In order to prevent recurrence, HR will document every new hires as "incomplete" when Proof of PPD testing (2 step) and notify DON of their inability to start working. All employees will be place in a tracking spread sheet containing the dated in which further documentation is due. DON, Scheduling and Administration will have access to this information.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019


B (PF#5)

b. Employee" Screening Employees For Tuberculosis" policy to be reviewed and updated as needed by Professional Advisory Committee. HR personnel are to be re-educated on the content of this policy.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming PPD tests were performed as per policy (2 step upon hire and 1 step yearly thereafter)
If documentation regarding PPD testing as per policy is not present for any or all of these periods, HR will notify employee of need for proof of PPD testing results document the name of the persons who are non compliant and send it to DON and Administrator . In the case that an employee or contractor is unable or unwilling to schedule PPD testing, a qualified replacement will be put in their place until such employee/contractor completes the required testing.
In order to prevent recurrence, HR will document every new hires as "incomplete" when Proof of PPD testing (2 step) and notify DON of their inability to start working. All employees will be place in a tracking spread sheet containing the dated in which further documentation is due. DON, Scheduling and Administration will have access to this information.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019


B (PF#9)

b. Employee" Screening Employees For Tuberculosis" policy to be reviewed and updated as needed by Professional Advisory Committee. HR personnel are to be re-educated on the content of this policy.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming PPD tests were performed as per policy (2 step upon hire and 1 step yearly thereafter)
If documentation regarding PPD testing as per policy is not present for any or all of these periods, HR will notify employee of need for proof of PPD testing results document the name of the persons who are non compliant and send it to DON and Administrator . In the case that an employee or contractor is unable or unwilling to schedule PPD testing, a qualified replacement will be put in their place until such employee/contractor completes the required testing.
In order to prevent recurrence, HR will document every new hires as "incomplete" when Proof of PPD testing (2 step) and notify DON of their inability to start working. All employees will be place in a tracking spread sheet containing the dated in which further documentation is due. DON, Scheduling and Administration will have access to this information.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019





601.21(d) REQUIREMENT
ADMINISTRATOR

Name - Component - 00
601.21(d) Administrator. The
qualified administrator, who may also
be the supervising physician or
registered nurse: (i) organizes and
directs the agency's ongoing
functions, (ii) maintains ongoing
liaison among the governing body, the
group of professional personnel, and
the staff, (iii) employs qualified
personnel and ensures adequate staff
education and evaluations, (iv)
ensures the accuracy of public
information materials and activities,
and (v) implements an effective
budgeting and accounting system. A
qualified person is authorized in
writing to act in the absence of the
administrator.

Observations:


Based on a review of agency documentation, agency policy, personnel files, clinical records, the administrator failed to organize and direct the agency's ongoing functions.

Findings included:

The administrator failed to ensure compliance with applicable Federal, State, and Local laws and regulations, regarding the Child Protective Services Law Background checks and employee screening for mycobacterium tuberculosis upon hire and annually. Refer to Tag 1000

The administrator failed to ensure a qualified registered nurse was appointed to the position of Director of Nursing and Assistant Director of Nursing. Refer to Tag 1006

The administrator failed to ensure personnel policies pertaining to qualifications and performance evaluations were followed. Refer to Tag 1007.

The administrator failed to ensure that there was documentation to show the professional advisory committee met at least annually to advise the agency on professional issues. Refer to Tag 1013

The administrator failed to ensure the "Home Health Certification and Plan of Care" included detailed physician orders for all care to be provided. Refer to Tag 1018

The administrator failed to ensure that the agency followed its policy regarding signing the plan of care/physician orders. Refer to Tag 1020

The administrator failed to ensure the registered nurse completed a timely and/or complete comprehensive assessment, and/or reviewed/updated the medication profile prior to the start of the certification period, failed to ensure the registered nurse (RN) and/or licensed practical nurse (LPN) perform and/or document care provided in accordance with the plan of care, and/or did not regularly communicate with the physician and nursing supervisor regarding new orders or changes in condition, and/or did not perform assessments according to the plan of care, and/or perform and/or document medication teaching. Refer to Tag 1023


An interview with the agency administrator, alternate administrator, assistant director of nursing trainee and operations manager on May 10, 2019, at approximately 11:30 A.M. confirmed the above findings.



























Plan of Correction:


a. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Employee Background Checks policy to be reviewed and updated as needed by Professional Advisory Committee and HR department.
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Employee Background Checks criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming background checks were performed on all employee and contractors upon hire.
If documentation regarding background checks is not present for any employee, HR will obtain a PA criminal background check and document results. Employees working with children will apply for child abuse clearances, copies of Childline applications will be placed in their file and employee be replaced with qualified personnel until results are received. Fingerprint clearances will be obtained for all employees that do not provide proof of residing in PA during the last 2 years.
- This includes: PF #2, PF #3, PF #5, PF #6, PF #7, PF #8, PF #9 and PF #10
PA Criminal background checks will be obtained upon hire for all employee and contractors. All new perspective employees will not be permitted to start working with children until Childline clearances are received. All employees with "pending' PA record results or FBI fingerprint results are to be directly supervised until results are obtained for a period no longer than 90 days.
Tracking system will be created for dates in which all of the background documents are due for re-checking.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

b. Employee" Screening Employees For Tuberculosis" policy to be reviewed and updated as needed by Professional Advisory Committee. HR personnel are to be re-educated on the content of this policy.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming PPD tests were performed as per policy (2 step upon hire and 1 step yearly thereafter)
If documentation regarding PPD testing as per policy is not present for any or all of these periods, HR will notify employee of need for proof of PPD testing results document the name of the persons who are non compliant and send it to DON and Administrator . In the case that an employee or contractor is unable or unwilling to schedule PPD testing, a qualified replacement will be put in their place until such employee/contractor completes the required testing.
- This includes: PF #2, PF #5 and PF #9
In order to prevent recurrence, HR will document every new hires as "incomplete" when Proof of PPD testing (2 step) and notify DON of their inability to start working. All employees will be place in a tracking spread sheet containing the dated in which further documentation is due. DON, Scheduling and Administration will have access to this information.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

c. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Clinical Manager/Director of Nursing and Assistance Director of Nursing and RN Supervisor Job Descriptions to be reviewed and updated as needed by Professional Advisory Committee.
It was decided that Administrator and Co Administrator will assume the positions of DON and ADON until qualified personnel are assigned to these positions.
RN's currently holding these positions will be assigned other qualified RN roles and will be oriented to their Job Description.
- This includes CR#1 and CR#4
To prevent future occurrences, Administrator will cross check Job descriptions with Applicant qualifications before hire.
Core Competency Skills/Employee Performance Criteria policy to be reviewed by Professional Advisory Committee
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Core Competency Skills/Employee Performance Criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming Core Competency Skill assessments were performed on all employee and contractors according to their specific disciplines during orientation process, at three months (along with 90 day performance evaluation) and at least annually (along with annual performance evaluation).
If documentation regarding competencies is not present for any or all of these periods, HR will document the name of the person, their specific discipline, the skills competency missing and send it to Administrator to schedule Skills competency assessments and evaluations (if needed). In the case that an employee or contractor is unable or unwilling to schedule a competency appointment, a qualified replacement will be put in their place until such employee/contractor completes the required competency and/or evaluation.
- This includes: PF #2, PF #3, PF #7,PF #8, PF #9, PF #11
Upon Hire, HR personnel will schedule initial skill competency assessment and place date on " Employee Documentation" spreadsheet as well as the projected dates of the 3 month and annual skills competency assessment and performance evaluations. Employees not documented on spreadsheet as having initial skills assessments will be marked as " not ready to start". During the month prior to next skills competency assessment, HR will establish communications with employee/contractor to schedule and confirm actual date of next skills competency assessment and discussion of performance evaluation. Employee performance evaluations will be tracked for the same date of skills competency assessments.
Employee/Contractor files will be audited quarterly during Quality Management Meetings to document compliance. Proper actions will be taken upon review of audit results.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

d. Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, and Board of Directors to discuss deficiencies.
Professional Advisory Committee policy to be reviewed and updated as needed to maintain compliance with regulations by Professional Advisory Committee and Board of Directors. PAC members will be oriented as needed.
PAC Meeting Minutes are to be documented signed and dated by all members of the committee and placed in "Minutes" book.
The Administrator will schedule next meeting to review current Plan of Correction, agency policies discussed in this plan of correction, personnel qualifications, and set up future meetings to be made at least twice per year and as needed for reviews ,updates or problems/issues that may arise.
All meetings made by the Board of directors in the past 3 years will also be evaluated by the Professional Advisory Committee during this meeting.
Administrator will maintain records of all pack meetings and ensure that they are all signed and dated by all members.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

e. Acceptance of patients/plan of treatment/care and medical supervision policies will be reviewed and updated as needed to ensure it includes information regarding the detailed components of the plan of care (outlined in 484.60 Condition of participation: Care planning, coordination of services, and quality of care).
The Administrator will schedule training sessions for all Nurses to provide education in the components of a patients plan of care as well as to CMS CoP and State Regulations concerning Plan of Treatment.
Clinical record audits will be performed on 100% of patients to determine elements/details individual plans of care currently lack.
Updates/addendums will be created to add specific details that are missing in patients 485's,including but not limited to:
1. Frequency and Duration of services
2. Frequency of treatments, including instruction
3. Supplies used to administer treatments, identifying model, type ,size , such as catheters used for catheterization, indwelling catheters and suction catheters.
4. Indwelling catheter/Perineal care instructions
5. Tracheostomy tube make, size, uncuffed/cuffed, volume of cuff, with changing frequencies and instructions. Tracheostomy care and patency check instructions and frequency.
6. Emergency track tube change equipment and instructions.
7. Feeding tubes (G, J or PEG) make, size, cuff water volume. Changing frequency, patency and site assessment frequency, tube care procedure and frequency.
8. Ventilators make/model, settings prescribed, documentation of settings checks frequency. Frequency of circuit change.
9. Specific wound care instructions including documentation of wound and location and progress/lack of.
All Addendums will be reviewed by DON and RN who created addendum prior to sending to Physician for review/approval All changes will be incorporated into the 485 document for next certification period.
Administrator and Quality management team member designee will audit 100% of clinical records previously audited to determine compliance.
On a Monthly basis , all 485's for new admissions will be reviewed by DON and RN who created plan of care/addendum to determine compliance in all areas of plan of care until 100% compliance is noted, then 25% of all admission will be audited quarterly during quarterly record reviews and quality management meetings to determine compliance. Administrator will review results. Additional actions needed will be determined during Quality Management Meetings.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

f. Acceptance of patients/plan of treatment/care and medical supervision policies will be reviewed and updated as needed to ensure it includes information regarding the detailed components of the plan of care (outlined in 484.60 Condition of participation: Care planning, coordination of services, and quality of care) as well as physicians signatures of orders/Plan of Care.
Tracking method to be reviewed and updated. All Plan of Care's for all patients will be placed on a tracking spreadsheet that includes:
i. Dates due ( start of care/Recertification date)
ii. Date sent to MD for Signature
iii. Weekly reminders/communications made with physicians regarding unsigned 485's including calls, faxes and emails.
iv. Communication/notification made to DON
When despite all efforts made, The agency does not receive the signed Plan of Care within 30 days Administrator and/or PAC will discuss Possible discharge from services and notify MD as well as patient ( following proper discharge notice procedure).
Administrator is responsible for implementation.
Date of Completion: 7/13/2019

g. Comprehensive Assessment of Patient and Coordination of Care " Policy will be reviewed and updated as needed by the Professional Advisory Committee. All RN's responsible for patient assessments and OASIS data collection will be in-serviced on policy, which includes required time frames for data collection on follow up assessments as well as to CMS CoP and State Regulations concerning follow up assessments.. A tracking system will be put in place for follow up assessments which will include all monthly dates in which follow up assessments are due for each patient over the age of 18 receiving skilled nursing. Skilled Nursing Services policy to be reviewed and updated as needed by Professional Advisory Committee .
The Administrator will schedule training sessions for all Nurses to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning integration of orders. The DON will complete mandatory in-services with the nursing staff to emphasize the need for coordination of care between members of the care team. This communication be placed in the medical record and/or case conference minutes, and will be monitored by the clinical supervisors responsible to ensure that the communication is taking place and being documented., and that if improvement is not noted, this could result in individual counseling, which could result in termination as they continue through the disciplinary process.
Administrator and Don will audit 100% of patient clinical records and determine areas that require improvement in coordination of care and Integration of orders. RN's coordination/integration of orders process includes, but is not limited to: the assurance of the following:
i. Every patient will be reviewed for coordination of care needs, establishment of care goals, progress and/or barriers reviewed, health status and any continued need for services.
ii. Medications and treatments orders are to be reviewed and reconciled as needed during each nursing visit, any discrepancies are to be clarified with physician and orders obtained if needed.
iii. Assure communication with all physicians involved in the plan of care.
iv. All orders obtained from physician will be added to patient treatment record or medication treatment record, to medication profile and an addendum/update will be made to the plan of treatment. Communications will be put in place for all nurses providing care to patient as well as patient/family regarding changes/updates.
v. All medications in patients home will be reviewed to determine if they are compliant with current medication orders.
vi. Any Medication that is not found in current plan of care will be discussed with MD to determine if an order has been made for this medication, needs to be obtained, has been made by another physician or if medication needs to be discarded.
vii. Nurses will provide education to Patient/family regarding orders and the need to discard/reorganize all other medications that are not ordered or order/dosages have changed. Nurses are to document patient/family compliance and report to md as needed. Communications with MD are to be placed in patient clinical record.
viii. Documentation needs to be in place when family administers all medications to patient or if no medications are administered during the time nurse is providing care.
ix. There must be orders for all medications listed in medication treatment record . All medication orders are to be obtained from physician prior to placing in medication treatment orders.
x. Recertification and ROC:
The RN Case Manager is responsible for collaborating with each identified care provider to identify progress and/or barriers to goals and documenting the progress and collaboration in the clinical record.
xi. Discharge: The RN Case Manager is responsible for communicating the planned discharge date to the other care providers as well as communicating the patient's
xii. Integrate orders from all physicians involved in the plan of care and interventions provided to the patient Integrate services, whether services are provided directly or under arrangement, to assure the identification of pt needs & factors that could affect pt safety & treatment effectiveness & the coordination of care provided by all disciplines.
xiii. Coordinate care delivery to meet the patient's needs, & involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities.
xiv. Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education & training provided by the HHA, as appropriate, regarding the care & services identified in the plan of care.
Any patient identified as needing improvement in any of the areas mentioned will be scheduled for care coordination conference as soon as possible. The RN Case Managers will address coordination of care with nurses as a component of their supervisory visits as the RN Case Manager, Visit Nurse ,Patient, Patient Representative (if any) will be available at the patient's place of residence at the time of the supervisory visits to discuss any items listed above as needed, patient family concerns, assess patient/family understanding of care and compliance. will be discussed,
The Administrator ,Director of Nursing and Quality Management designee will review all records monthly for coordination of care and inclusions of case conference for patients receiving care for more than one certification period. This will occur until there is 100%compliance. Then 20% of patient records will be reviewed quarterly during record reviews and quality management meetings.

Administrator is responsible for implementation.
Date of Completion: 7/13/2019



601.21(e) REQUIREMENT
SUPERVISING PHYS OR REGISTERED NURSE

Name - Component - 00
601.21(e) Supervising Physician or
Registered Nurse. The skilled nursing
and other therapeutic services
provided are under the supervision and
direction of a physician or a
registered nurse (with at least one
year of nursing experience). This
person or similarly qualified
alternate, is available at all times
during operating hours and
participates in all activities
relevant to the professional services
provided, including the development of
qualifications and assignment of
personnel.

Observations:


Based on review of agency job descriptions, employee personnel (PF) files, and an interview with the administrator, assistant director of nursing trainee, the alternate administrator, and the operations manager, the governing body and the administrator failed to ensure a qualified registered nurse (RN) was appointed to the position of director of nursing (DON) and assistant director of nursing (ADON).

Findings included:

On May 10, 2019, at approximately 11:00 A.M., review of the agency job description titled "Director of Nursing" revealed the following:
"E. Education and Experience: 2. Experience: a. Minimum three (3) years experience in nursing, with at least two (2) years in home health or community health nursing required. b. Minimum one (1) year in a supervisory or management position..."

On May 10, 2019, at approximately 11:00 A.M., review of agency job description titled "Assistant Director of Nursing Trainee" revealed the following:
"E. Education and Experience: 2. Experience: a. experience in nursing, with at least two (2) years in home health or community health required..."

A review of personnel files conducted on May 10, 2019, from approximately 9:30 A.M. to 10:30 A.M. revealed the following:

PF #1, Assistant Director of Nursing Trainee: date of hire April 17, 2019. Pennsylvania State RN license documentation revealed the RN license was issued on April 16, 2019. The employee's application notes graduation from Aria Health School of Nursing in 2019. There was no documentation that the Assistant DON trainee met the qualifications for supervising nurse under 28 Pa. Code, Part IV, Health Facilities, and Subpart G. Chapter 601 and agency policy.

PF #4, Director of Nursing: date of hire September 18, 2018, Pennsylvania State Registered Nurse (RN) license documentation revealed the RN license was issued on August 21, 2018. The employee's resume lists graduation from Aria Health School of Nursing on June 25, 2018. There was no documentation that the DON met the qualifications for supervising nurse under 28 Pa. Code, Part IV, Health Facilities, and Subpart G. Chapter 601 and agency policy.

An interview with the administrator, alternate administrator, assistant director of nursing trainee, and director of operations on May 10, 2019, at approximately 11:30 A.M. confirmed the above findings.


































Plan of Correction:

Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Clinical Manager/Director of Nursing and Assistance Director of Nursing and RN Supervisor Job Descriptions to be reviewed and updated as needed by Professional Advisory Committee focusing education and experience requirements
It was decided that Administrator and Co Administrator will assume the positions of DON and ADON until qualified personnel are assigned to these positions.
RN's currently holding these positions will be assigned other qualified RN roles and will be oriented to their Job Description.
- This includes CR#1 and CR#4
To prevent future occurrences, Administrator will cross check Job descriptions with Applicant qualifications before hire. All changes made in management will be sent in writing to the department of health 30 days prior to implementation date.
Administrator is responsible for implementation.
Date of Completion: 7/13/2019



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 agency policy, employee personnel files (PF), and interview with agency staff, it was determined the agency failed to ensure personnel policies pertaining to qualifications and performance evaluations are followed six (6) of eleven (11) PF reviewed. (PF# 2, 3, 7. 8, 9, and 11).

Findings Included:

Review of agency policy #HR-12.0 "Core Competency Skills/Employee Performance Criteria" on May 10, 2019, at approximately 10:30 A.M. revealed:
"Procedure: Core Competency Skills: 1. Elite Home Health Care will define the mandatory core competency skills for each discipline based upon the nature of their job responsibilities and complexity of care required. Discipline specific Competency Skill Assessment Checklists (copies attached) will be reviewed with new personnel during their orientation based on their specific disciplines... Employee Performance Criteria: 1. Agency personnel will demonstrate proficiency in the performance criteria/skills during their orientation period which must be demonstrated at three (3) months and at least, annually thereafter as part of the annual performance evaluation process...."

A review of PF conducted on May 10, 2019, at approximately 9:00 A.M. revealed the following:

PF #2, date of hire 2005, did not contain documentation of annual performance evaluations from 2006 through 2018.

PF #3, date of hire August 10, 2017, did not contain documentation of an annual performance evaluation in 2018 .

PF #7, date of hire October 27, 2017, did not contain documentation of an annual competency evaluation for 2018.

PF #8, date of hire January 8, 2018, did not contain documentation of a three month or an annual performance evaluation in 2019.

PF #9, date of hire January 25, 2018, did not contain documentation of a three month or an annual performance evaluation in 2019.

PF #11, date of hire April 6, 2019, did not contain documentation of an initial competency test or skills evaluation upon hire.

An interview with the administrator, alternate administrator, assistant director of nursing trainee, and operations manager on May 10, 2019, at approximately 11:30 A.M. confirmed the above items were not present in the personnel files.
























































Plan of Correction:

Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Core Competency Skills/Employee Performance Criteria policy to be reviewed by Professional Advisory Committee
The Administrator will schedule training sessions for all HR personnel to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning Core Competency Skills/Employee Performance Criteria.
Human Resources Manager will review each employee/contractor file to determine if documentation is present confirming Core Competency Skill assessments were performed on all employee and contractors according to their specific disciplines during orientation process, at three months ,along with 90 day performance evaluation and at least annually along with annual performance evaluation.
If documentation regarding competencies and evaluations are not present for any or all of these periods, HR will document the name of the person, their specific discipline, the skills competency missing and send it to Administrator to schedule Skills competency assessments and evaluations (if needed). In the case that an employee or contractor is unable or unwilling to schedule a competency appointment, a qualified replacement will be put in their place until such employee/contractor completes the required competency and/or evaluation.
- This includes: PF #2, PF #3, PF #7,PF #8, PF #9, PF #11
Upon Hire, HR personnel will schedule initial skill competency assessment and place date on " Employee Documentation" spreadsheet as well as the projected dates of the 3 month and annual skills competency assessment and performance evaluations. Employees not documented on spreadsheet as having initial skills assessments will be marked as " not ready to start". During the month prior to next skills competency assessment, HR will establish communications with employee/contractor to schedule and confirm actual date of next skills competency assessment and discussion of performance evaluation. Employee performance evaluations will be tracked for the same date of skills competency assessments.
Employee/Contractor files will be audited quarterly during Quality Management Meetings to document compliance. Proper actions will be taken upon review of audit results.
Administrator is responsible for implementation
Date of Completion: 7/13/2019



601.22(b) REQUIREMENT
ADVISORY AND EVALUATION FUNCTION

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

Observations:


Based on an interview with the agency operations manager, review of agency policy, and review of agency meeting minutes, the agency failed to ensure there was documentation to show the professional advisory committee met at least annually to advise the agency on professional issues.

Findings included:

Review of agency policy #A-5.0, "Professional Advisory Committee (PAC)" on May 10, 2019, at approximately 10:30 A.M. states, "Procedure: 9. The PAC will meet twice per year or as often as needed... B. All meetings are documented by dated minutes and will include attendees' names and supporting documentation of applicable."

Review of agency meeting minutes on May 8, 2019, at approximately 11:00 A.M. revealed no minutes of the PAC for 2017, 2018 or 2019.

An interview with the operations manager on May 10, 2019, at approximately 8:30 A.M. revealed that the agency did not retain written documentation of the PAC meetings.

An interview with the administrator, alternate administrator, assistant director of nursing trainee, and operations manager on May 10, 2019, at approximately 11:30 A.M. confirmed that professional advisory committee meeting minutes have not been retained in accordance with agency policy.






















































Plan of Correction:

Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, and Board of Directors to discuss deficiencies.
Professional Advisory Committee policy to be reviewed and updated as needed to maintain compliance with regulations by Professional Advisory Committee and Board of Directors. PAC members will be oriented as needed.
PAC Meeting Minutes are to be documented signed and dated by all members of the committee and placed in "Minutes" book.
The Administrator will schedule next meeting to review current Plan of Correction, agency policies discussed in this plan of correction, personnel qualifications, and set up future meetings to be made at least twice per year and as needed for reviews ,updates or problems/issues that may arise.
All meetings made by the Board of directors in the past 3 years will also be evaluated by the Professional Advisory Committee during this meeting.
Administrator will maintain records of all pack meetings and ensure that they are all signed and dated by all members.
Administrator is responsible for implementation
Date of Completion: 7/13/2019



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 policies, clinical records (CR), and interviews with the administrator, the alternate administrator, and the assistant director of nursing trainee, the agency failed to ensure that the "Home Health Certification and Plan of Care" (POC) included detailed physician orders for all care to be provided for five (5) of seven (7) CR reviewed. (CR # 2, 3, 4, 6 and 7)

Findings included:

On May 10, 2019, at approximately 10:30 A.M., review of the agency policy # C-2.0 titled "Acceptance of Patients, Plan of Treatment/Care and Medical Supervision" revealed the following:
" Procedure: 2. Plan of Care: Care follows a written plan of care established and periodically reviewed by a doctor of medicine, osteopathy or podiatric medicine (physician). A. The plan of care is established by the appropriate agency staff after consultation with the physician, other agency personnel, patient, family and/or caregiver. B. The plan includes: i. Pertinent Diagnosis, ii. Mental Status, iii. Types of services and equipment required, iv. Frequency of visits, v. Prognosis, vi. Rehabilitation potential, vii. Functional limitations. Viii. Activities permitted, ix. Nutritional requirements, x. Medications & treatments, xi. Safety measures to protect against injury, xii. Instructions for timely discharge or referral, xiii. Any other pertinent items, xiv. Orders of therapy services include the specific procedures and modalities to be used, and the amount, frequency and duration of treatment ... "

Review of clinical records (CR) on May 9, 2019, from approximately 9:00 A.M. to 2:30 P.M. revealed the following:

CR #2, start of care December 21, 2018. Diagnoses include tracheostomy status (presence of a tracheostomy tube to maintain the airway), apnea not elsewhere classified (cessation of breathing), anemia of prematurity (low iron) and gastrostomy status (feeding tube inserted through abdomen into stomach).
Review of Orders for Discipline and Treatment for certification period April 20, 2019, through June 18, 2019 revealed the following:
Skilled nursing 8 hours per night, Friday, Saturday, and Sunday: 10PM to 6AM
To cover any additional shifts not staffed by primary agency.
To assess all body systems with a special attention to the respiratory system.
Vital signs every shift: Temperature, Respirations, Pulse, and Pulse Ox (measurement of oxygen saturation). Report any abnormal findings to the primary caregiver, MD, and supervisor.
Assess and maintain airway patency at all times. Tracheal suction as needed or as directed by primary caregivers. Perform trach (tracheostomy) care every 8 hours; cleanse with mild soap and water, pat dry, apply 2x2 drain sponge around trach site. Weekly trach changes with mom and SN (skilled nurse). Assess for signs of skin breakdown; redness irritation, or moisture.
Monitor and report abnormal secretory findings.
Assess and maintain skin integrity every shift.
Administer feedings as ordered, maintain aspiration precautions at all times.
Assess tolerance to feeds and monitor and report any signs and symptoms of feeding intolerance.
Administer medications via G-tube (gastrostomy tube). Flush G-tube with 3 mL(milliliters) of water after medications and feeds. Assess G-tube patency and site.
Monitor and report any adverse effects to primary caregiver, MD (medical doctor), and nursing supervisor.
Report all changes to from baseline to primary caregiver, MD, and nursing supervisor.
Maintain patient safety at all times.
Trach (tracheostomy tube) size: 3.5 Bivona Flex
Will begin sprints (short periods of time off the ventilator) to HME (heat and moisture exchanger) for 15-30 minutes twice a day as tolerated.
Call the Pulmonary department TDC program weekly with updates on the monitoring parameters listed below, which will determine readiness for wean.
*Continued weight gain or growth is just as important as all other vital signs*
Monitoring Parameters:
Monitor work of breathing, adequate level of daytime wakefulness and activity/tolerance of therapies.
Check these vital signs just before the wean starts and again before returning to the usual ventilator settings; Sp02 (peripheral capillary oxygen saturation or estimated oxygen level in blood), EtCO2 (end-tidal carbon dioxide), HR (heart rate), and RR (respiratory rate). As the wean times increase, monitor the vital signs every hour.
If the HR or RR increases more than 20% or the saturations decrease to less than 92%, stop the wean.
Also obtain ETCO2 before the wean/sprint and at the end of the wean/sprint prior to going back on the higher settings or vent. If you need to end the sprint early, obtain an ETCO2 and full vital signs.
Weight will need to be checked on a weekly basis, using the same scale at the same time of day, ideally while naked or with a dry diaper. "

The Orders for Discipline and Treatment lack the following details:

Frequency and duration of skilled nursing services
Volume of tracheostomy tube cuff, emergency tracheostomy tube change instructions, frequency of tracheostomy tie changes.
Ventilator make/model, ventilator settings, including mode, peak inspiratory pressure (PIP), PEEP (positive end expiratory pressure), fraction of inspired oxygen (FiO2), inspiratory time, tidal volume, respiratory rate, heat and humidification, alarm settings, ventilator circuit change frequency.
Frequency, suction catheter type/size, depth of suctioning.
Size and type of G-tube, the amount of water to be instilled into the cuff, frequency of G-tube changes, frequency of assessment of G-tube patency and site, G-tube care procedure and frequency.

CR #3, start of care January 22, 2018. Diagnoses include cerebral palsy (congenital disorder of movement, muscle tone, or posture), unspecified, neuromuscular scoliosis (curvature of the spine), site unspecified, pseudobulbar affect (pathological laughter and crying), unspecified asthma (constriction of airways), uncomplicated.
Review of Orders for Discipline and Treatment for certification period March 18, 2019, through May 16, 2019 revealed the following orders that do not contain sufficient detail:
SN (skilled nursing) 28 hours a week, 4 visits a day:
To assess all body systems and report abnormal findings to MD (medical doctor)
Vital signs every visit
Assess lung sounds and respiratory effort every visit
Straight cath (catheterization) four times a day
Monitor for signs of urinary tract infections, report to MD any unusual findings
Record urinary output every visit
Incontinent care as needed
Assess skin for signs of breakdown, report to MD any unusual findings
Provide safety at all times

The Orders for Discipline and Treatment lack the following details:

Duration of skilled nursing services
Type and size of catheter to be used for straight catheterization

CR #4, start of care March 16, 2019. Diagnoses include congenital malformation of heart, unspecified, ventricular septal defect (abnormal connection between the lower chambers of the heart), stenosis of pulmonary artery (narrowing of the blood vessel that carries blood from the right ventricle of the heart to the lungs), gastrostomy status.
Review of Orders for Discipline and Treatment for certification period March 18, 2019, through May 16, 2019 revealed the following:
Skilled nursing 24 hours a week; 12 hours Saturday and 12 hours Sunday, and to provide coverage for other agency
Perform and assess vital signs: Temperature, HR, RR, and B/P (blood pressure) as tolerated by (patient). Assess all body systems, patient/caregiver knowledge of disease process and associated care and treatment, medication regimen, knowledge and signs and symptoms of complications necessitating medical attention.
Assess, teach, manage, evaluate, and perform fall prevention intervention. Maintain constant supervision of (patient) and ensure safety at all times.
Perform interventions to monitor and mitigate pain. Use FLACC (face, legs, activity, cry, consolability scale) to help assess for signs of pain.
Assess for signs and symptoms of complication and infection to include redness, open areas, elevation in temperature. Perform full skin assessment every shift. Change frequently and as needed, but no less than every two hours. Report any abnormal findings to primary caregiver, supervisor and MD.
Assess respiratory status. Perform methods to recognize pulmonary dysfunction and relieve complications.
Assess cardiac status for methods to recognize and relieve complications. Report any signs of decreased cardiac output immediately to primary caregiver, MD and supervisor. (abnormal HR, low blood pressure, prolonged capillary refill, changes in mental status etc.)
Weigh patient per MD visit and update agency following each visit.
Perform measures to manage, recognize and relieve symptoms of GERD; administer medications as prescribed, proper positioning during meals, etc.
Perform measuring and recording of intake and output
Manage gastrostomy tube as follows: 1. Assess site at the start and end of each shift. Check placement. Clean with soap and water every shift and pat dry. Apply 2x2 if available. Report any and all abnormal findings to primary caregiver, supervisor, and MD.
Manage enteral nutrition as follows Monogan formula run continuously at 35 mL/hr via G-tube with care of equipment to include feeding pump, pole, feeding bags and extension tubing. Perform gastrostomy tube flush with 10 mL of water after each feed.
Assess changes in level of consciousness or neurological status
Perform circulatory checks report any discoloration or prolonged refill time immediately
Perform medication set up and compliance. Perform medication regimen to include name, dose, frequency, route, desired action, side effects, interactions, adverse reactions, recognition of problems and how to report.
Flush G-tube with 5 mL of water after each medication.
*Report any and all abnormal findings to primary caregiver, MD, and supervisor immediately
*Report all changes in medications to supervisor immediately

The Orders for Discipline and Treatment lack the following details:

Duration of skilled nursing services
Size and type of G-tube, amount of water to be instilled into the cuff, frequency of G-tube changes.

CR #6, start of care August 21, 2017. This patient has been hospitalized effective April 15, 2019. Diagnoses include other reduction deformities of brain (abnormally small convolutions in the brain), chronic respiratory failure, unspecified with hypoxia (lack of oxygen) or hypercapnia (elevated levels of carbon dioxide in the blood), parainfluenza virus pneumonia, lobar pneumonia (affects a large area of the lobe of the lung), unspecified organism, unspecified lack of expected normal physiological development in childhood, other cerebral palsy, Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus, tachypnea (rapid breathing), not elsewhere classified, Gastrostomy status.
Review of Orders for Discipline and Treatment for certification period April 13, 2019, through June 11, 2019 revealed the following:
Skilled Nursing 16 Flex hours on weekends when parents work, a continuation of overnight nursing from 11PM to 7AM, 7 days per week, to allow mom to sleep at night, complete household chores, shop, go to church, to tend family needs and care for her other 4 children's needs, and provide a safe environment for (patient) while she is out of the home.
To assess all body systems with attention to respiratory system: to assess respiratory rate, lung sounds work of breathing and secretory status.
Vital signs every shift: temperature, heart rate, blood pressure when possible.
Continuous pulse ox monitoring, may remove probe during bath and to replace, oxygen up to 3 LPM as needed to maintain a pulse ox above 92%. Notify MD if need to titrate to 3 LPM or more.
Assess patency of G-tube, and site
G-tube feedings as prescribed, followed by 100 ml flush
Assess and monitor for signs and symptoms of feeding intolerance: report to supervisor, MD, and caregiver
Assess bowel sounds, document all bowel movements, Report any abnormal findings.
Assess for signs of infection and report abnormal findings to supervisors, MD, and caregiver.
Maintain aspiration precautions at all times.
Chest PT (physiotherapy) 5 minutes, 4 times a day as tolerated
Percussion vest: Pressure control 30: frequency 1 -6 hertz- for 10 minutes, frequency 2- 10 hertz for 10 minutes, frequency 3- 12 hertz for 10 minutes.
Cough assist: positive pressure 25, negative pressure 25: 5 reps (repetitions), twice a day
Suction s needed: document amount, color, consistency, of secretions as well as frequency of suctioning.
BiPAP overnight: IPAP 20, EPAP 14, rate of 18, oxygen 2 LPM (liters per minute)
Maintain seizure precautions at all times: document time, type, and frequency of seizures. Administer emergency seizure mediation as ordered. Notify mother, and MD upon emergency drug administration. Document all communications.
Maintain safety at all times
Incontinence care every two hours and as needed
Turn and reposition every two hours and as needed to maintain comfort.
Maintain skin integrity at all times: monitor for signs of breakdown and report any abnormal findings to supervisor, MD and caregiver.


The Orders for Discipline and Treatment lack the following details:

Frequency and duration of skilled nursing services
Assessment of patency of G-tube and site does not list a frequency

CR #7, start of care February 11, 2019. Diagnoses include paraplegia (paralysis of the lower half of the body), unspecified, pressure ulcer of other site, stage 2, chronic respiratory failure, unspecified with hypoxia or hypercapnia, urinary tract infection, site not specified, major depressive disorder, recurrent severe without psychotic features, vitamin deficiency, unspecified, dysphagia (difficulty swallowing), unspecified, pain, unspecified, acquired absence of right leg above knee, cachexia (weakness and wasting of the body), gastrostomy status.
Review of Orders for Discipline and Treatment for certification period February 11, 2019, through April 11, 2019 revealed the following:
Skilled nursing Monday - Sunday, 24 hours a day
Skilled assessment of all systems and report abnormal findings to MD
Vital signs once a shift as tolerated: Temperature, HR (heart rate), RR (respiratory rate), and blood pressure
Document any refusal/noncompliance of care/medication administration in progress notes.
Patient education and teaching on disease process and medication management including side effects
Patient education on all safety and infection precautions instruct on when and why to contact MD
Educate patient on urgent versus non-urgent care needs
Perform chest PT (physiotherapy) as tolerated and as allowed, document all noncompliance/refusal
Report any abnormal findings or worsening of wounds to supervisor, family and MD
Keep HOB elevated 30 degrees, and maintain aspiration precautions during meals.
Maintain airway patency at all times.
Provide safety at all times through constant supervision
Maintain Peg tube, check for patency and placement before administering medications
Assess Peg tube site daily for signs of inflammation/infection (redness, drainage, odor), Report to MD
Assess indwelling catheter every shift for signs of infection, provide catheter and perianal care every shift
Flush foley with 30 ml water every shift to ensure patency and placement
Empty foley drainage bag and document output as well as urine color, odor, and consistency every shift.
Wound care:
Cleanse wounds with normal saline and pat dry
Apply Bactroban ointment twice a day to affected areas.


The Orders for Discipline and Treatment lack the following details:

Duration of skilled nursing services
Frequency and duration of chest PT
Frequency of wound care and location of wounds
Size and type of tube, frequency of Peg tube changes
Type and size of indwelling catheter, frequency of changes, details of catheter care or perianal care to be performed

An interview with the agency administrator, alternate administrator and the alternate director of nursing trainee on May 10, 2019, at approximately 11:30 A.M. confirmed the above findings.









































Plan of Correction:

Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator and Nursing department to discuss PA DOH deficiencies from 05/14/2019
Acceptance of patients/plan of treatment/care and medical supervision policies will be reviewed and updated as needed to ensure it includes information regarding the detailed components of the plan of care (outlined in 484.60 Condition of participation: Care planning, coordination of services, and quality of care).
The Administrator will schedule training sessions for all Nurses to provide education in the components of a patients plan of care as well as to CMS CoP and State Regulations concerning Plan of Treatment.
Clinical record audits will be performed on 100% of patients to determine elements/details individual plans of care currently lack.
Updates/addendums will be created to add specific details that are missing in patients 485's, including but not limited to:
j. Frequency and Duration of services
k. Frequency of treatments, including instruction
l. Supplies used to administer treatments, identifying model, type ,size , such as catheters used for catheterization, indwelling catheters and suction catheters.
m. Indwelling catheter/Perineal care instructions
n. Tracheostomy tube make, size, uncuffed/cuffed, volume of cuff, with changing frequencies and instructions. Tracheostomy care and patency check instructions and frequency.
o. Emergency track tube change equipment and instructions.
p. Feeding tubes (G, J or PEG) make, size, cuff water volume. Changing frequency, patency and site assessment frequency, tube care procedure and frequency.
q. Ventilators, C or bi pap , percussion equipment and respiratory treatment equipment will be listed in 485 along with the make/model, settings prescribed, documentation of settings checks frequency, Frequency of circuit change and any special instructions.
r. Specific wound care instructions including documentation of wound and location and progress/lack of.
All Addendums will be reviewed by DON and RN who created addendum prior to sending to Physician for review/approval All changes will be incorporated into the 485 document for next certification period.
- This includes CR# 2, 3, 4, 6 and 7
Administrator and Quality management team member designee will audit 100% of clinical records previously audited to determine compliance.
On a Monthly basis , all 485's for new admissions will be reviewed by DON and RN who created plan of care/addendum to determine compliance in all areas of plan of care until 100% compliance is noted, then 25% of all admission will be audited quarterly during quarterly record reviews and quality management meetings to determine compliance. Administrator will review results. Additional actions needed will be determined during Quality Management Meetings.
Responsible person(s): Administrator and DON
Date of Completion: 7/13/2019



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), review of agency policy, and interview with the agency operations manager, the agency failed to follow its policy regarding signing the plan of care/of physician orders for three (3) of seven (7) CR reviewed. (CR# 2, 3, and 5).

Findings included:

Review of policy # C-1.0 "Referral, Intake Process and Assessment Visit" on May 10, 2019, at approximately 10:30 A.M. states, "Procedure: 3. Plan of Treatment/Care, B. Review of the plan of Treatment/Care: ii. The original Plan of Treatment/Care and any modifications shall be signed by the patient's physician within seven (7) days..."

An interview with the agency operations manager on May 10, 2019, at approximately 9:00 A.M. revealed that the agency has difficulty with obtaining signatures for orders with certain physicians. The agency staff resubmit orders and retain documentation of all attempts to obtain signatures, either by fax, telephone or in person.

A review of the clinical records conducted on May 9, 2019, from approximately 9:00 A.M. to 2:30 PM revealed the following:

CR #2, start of care December 21, 2018, contained a Home Health Certification and Plan of Care (POC) for certification period December 21, 2018, through February 21, 2019, which was not signed by the physician. The POC for the certification period February 19, 2019 through April 19, 2019, was signed by the physician on April 22, 2019, 62 days after the start of the certification period. The POC for the certification period April 20, 2019, through June 18, 2019, was not signed by the physician as of May 9, 2019, 19 days after the start of the certification period.

CR #3, start of care January 22, 2018, contained a POC for certification period March 18, 2019, through May 16, 2019, was not signed by the physician as of May 9, 2019, 53 days after the start of the certification period.

CR #5, start of care March 7, 2019, contained a POC for certification period March 7, 2019, through May 5, 2019, was not signed by a physician as of May 9, 2019, 64 days after the start of the certification period.

An interview with the administrator, alternate administrator, assistant director of nursing trainee, and operations manager on May 10, 2019, at approximately 11:30 A.M. confirmed the above findings.




































Plan of Correction:

"Acceptance of patients/plan of treatment/care and medical supervision" and Referral, Intake Process and Assessment Visit" policies will be reviewed and updated as needed to ensure it includes information regarding the detailed components of the plan of care (outlined in 484.60 Condition of participation: Care planning, coordination of services, and quality of care) as well as physicians signatures of orders/Plan of Care within 7 days.
Tracking method to be reviewed and updated. All Plan of Care's for all patients will be placed on a tracking spreadsheet that includes:
v. Dates due ( start of care/Recertification date)
vi. Date sent to MD for Signature
vii. Weekly reminders/communications made with physicians regarding unsigned 485's including calls, faxes and emails.
viii. Communication/notification made to DON
When despite all efforts made, The agency does not receive the signed Plan of Care within 30 days Administrator and/or PAC will discuss Possible discharge from services and notify MD as well as patient (following proper discharge notice procedure).
- Including CR#5
Responsible person(s): Administrator and DON
Date of Completion: 7/13/2019



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 agency policies, clinical records, and interview with the agency staff, the agency failed to ensure the registered nurse (RN) completed a timely and/or complete comprehensive assessment, and/or review/update of the medication profile prior to the start of the certification period, ensure the registered nurse (RN) and/or licensed practical nurse (LPN) perform and/or document care provided in accordance with the plan of care, and/or did not regularly communicate with the physician and nursing supervisor regarding new orders or changes in condition, and/or did not perform assessments according to the plan of care, and/or perform and/or document medication teaching for seven (7) of seven (7) clinical records (CR) reviewed. (CR #1, 2, 3, 4, 5, 6, and 7).

Findings included:

On May 10, 2019, at 10:00 A.M., review of agency policy #C-12.0 Skilled Nursing Services states: Procedure: "1. The Nursing Supervisor coordinates, supervises and oversees the provision of nursing services. The Nursing Supervisor's role is to: 1. B. Ensure that all personnel furnishing services maintain liaison and that their efforts are coordinated effectively, managed and follow the objectives outlined in the patient's plan of care. C. Guarantee that the clinical recorded or minutes of case conferences establish that effective interchange, reporting and coordination of patient care does occur. 2. Each patient at Elite Home Health Care is assigned a primary care RN. The primary care nurse is responsible for the following which is documented in each patients clinical record: B. Completing a comprehensive patient assessment which includes: ii. A review of all medications the patient is currently using to identify: a. any potential adverse effects and drug reactions, including ineffective drug therapy; b. any significant side effects and/or significant drug interactions; c. any duplicate drug therapies; and d. any non-compliance with drug therapy. c. Admission of patients for service and development of the patient care plan... I. Regular evaluation of the patient's progress, prompt action when any change in the patient's condition is noted or reported, and termination of care when goals of management are attained... R. Preparing and submitting required clinical record documentation... S. Informing physicians, home health care staff and interdisciplinary team members of changes in the patient's condition and needs... V. Participating in and completing the discharge planning process for patients... X. The duties of the LPN include: i. Provides care and treatments as directed and supervised by the RN and/or ordered by a physician. ii. Implements the plan of care and evaluating the patient's progress towards expected outcomes. iii. Assists the patient in learning self care techniques. iv. Prepares clinical and progress note documentation. v. Communicates with physicians and staff members about changes in the patient's status..."

A review of clinical records conducted on May 9, 2019, from 9:00 A.M. to 2:30 P.M revealed the following:

CR #1, start of care August 14, 2017, contained a comprehensive assessment conducted on April 15, 2019, for the certification period April 6, 2019, through June 4, 2019, which was nine (9) days after the start of the certification period.

CR #2, start of care December 21, 2018, contained a comprehensive assessment dated March 11, 2019, for the certification period February 19, 2019, through April 19, 2019, which was twenty (20) days after the start of the certification period. The CR did not contain evidence of a comprehensive assessment completed for the certification period April 20, 2019, through June 18, 2019. The comprehensive assessment conducted on March 11, 2019, does not contain details regarding tracheostomy tube, ventilator, and gastrostomy tube. The medication treatment record in the patient's home was updated (by the nurse working in the home) to include the following medications that were ordered on March 5, 2019: 1. Sodium Chloride 0.9% (saline) inhalation, 2. Levabuterol (bronchodilator) HFA inhaler, 3. Budesonide (steroid) dosage was changed. There was no evidence that a verbal order was obtained for these medications, nor were they added to the medication profile. During the home visit #2 conducted on May 8, 2019, at approximately 3:00 P.M., five (5) medications were noted on the Medication Treatment Record (in the home) for April, 2019, as discontinued. Fursoemide (diuretic), Aldactazide (diuretic), Potassium chloride (electrolyte), Revatio (vasodilator), and Sodium Chloride tablet (electrolyte). On April 6, 2019, Cetirizine HCl (antihistamine) was added to the home Medication Treatment Record. There was no evidence that the nursing supervisor was notified of the medication changes by the RN working in the home. There was no evidence that a verbal order was obtained for this medication, nor was the medication added to the medication profile. There was no evidence that the nursing supervisor reviewed and updated the medication profile.
Nursing flow sheets for the certification period April 20, 2019, through June 18, 2019, contained no detailed documentation regarding the care provided as it relates to the tracheostomy tube, ventilator, oxygen, suctioning, and G-tube.


CR #3, start of care January 22, 2018, contained a comprehensive assessment dated March 18, 2019, for the certification period March 18, 2019, through May 16, 2019. The comprehensive assessment completed for the certification period March 18, 2019, through May 16, 2019, conducted on March 18, 2019, did not contain details regarding the foley catheter. During the home visit #3 conducted on May 8, 2019, at approximately 3:45 P.M., the CR's medications were found in a dresser drawer. There were seven (7) bottles of various expired prescription medications. There were two (2) bottles of prescription medications with labels that were worn and faded to the point that it was impossible to determine the patient name, drug name, dose, route, expiration date, or physician ordering the medication. There was one tube of antibiotic ointment in the drawer without a cap. There were multiple prescription bottles containing duplicate medications with different dosages and strengths. It was noted that the family administers all of the CR's medications. There was no evidence that the nursing supervisor reviewed and updated the medication profile. The Straight Intermittent Catheterization Flow Sheets completed by the LPN did not contain an assessment of all body systems as ordered on the POC for the certification period March 18, 2019, through May 16, 2019, nor did it contain details regarding the size of the foley catheter used for the procedure.

CR #4, start of care March 16, 2019, contained a comprehensive assessment dated March 16, 2019, for certification period March 16, 2019, through May 14, 2019. The comprehensive assessment completed for the certification period March 16, 2019, through May 14, 2019, did not contain details regarding the gastrostomy tube. The dosage of Propranolol (cardiac, beta blocker), Flax Seed Oil (supplement), and Acetaminophen (pain, fever) listed on the medication profile dated March 16, 2019, did not match the dosage listed on the Medication Treatment Record for March, 2019. There were four (4) additional medications on the Medication Treatment Record that were not listed on the medication profile, Nystatin Triamcinolone cream (anti-fungal/anti-inflammatory), Hydrocortisone 2.5% cream (anti-inflammatory), Mupirocin 2% ointment (topical antibiotic), and Clindamycin (antibiotic). There was no documentation in the nursing notes that verbal orders were obtained or that the agency was notified of the medication changes by the LPN working in the home. There was no evidence that the nursing supervisor reviewed and updated the medication profile. It was noted in the CR that the mother administers all medications via the G-tube.

CR #5, start of care March 7, 2019, contained a comprehensive assessment dated March 11, 2019, five (5) days after the start of care. The first home heath aide shift documented was on March 18, 2019. The CR did not contain a comprehensive assessment for the certification period May 5, 2019, through July 4, 2019.

CR #6, start of care August 21, 2017, contained a reassessment visit on April 9, 2019, for the certification period April 13, 2019, through June 11, 2019. The patient was admitted to the hospital on April 15, 2019, and has not received care since that time. The CR contained a verbal order to hold services beginning April 16, 2019. The comprehensive assessment completed on April 13, 2019, does not address details regarding the G-tube, BiPAP (Bilevel Positive Airway Pressure), suctioning, or oxygen. Nursing flow sheets for the certification period April 13, 2019, through June 11, 2019, did not contain detailed documentation regarding the G-tube, BiPAP (Bilevel Positive Airway Pressure), suctioning, or oxygen. The patient was admitted to the hospital on April 15, 2019, and has not returned home as of May 9, 2019. There was no evidence of a discharge order, discharge assessment or discharge summary.

CR #7, start of care February 11, 2019, contained an assessment that was not dated. The assessment noted wounds on the left foot, left knee, right amputation, coccyx, and both "mid upper backsides". There was no documentation of measurement, staging, or description of the wounds. The comprehensive assessment did not contain details regarding the G-tube or the foley catheter. The patient was admitted to the hospital on February 20, 2019, and has not received home health services since that date. The CR contained an order to hold services for hospital admission on February 20, 2019. The CR did not contain a discharge order, discharge assessment or discharge summary. The certification period ended April 11, 2019. The medication profile contained a duplicate order for Vitamin C. The CR contained no nursing flow sheets for the certification period. Nursing flow sheets from the previous certification period, February 12, 2019, through April 12, 2019, contained no documentation of the wounds noted on the reassessment completed on April 9, 2019. There was no detailed documentation of an assessment of all body systems, or care pertaining to the G-tube or the foley catheter.

An interview with the administrator, alternate administrator and assistant director of nursing trainee on May 10, 2019, at approximately 11:30 A.M. confirmed that registered nurse (RN) failed to complete a timely and/or complete comprehensive assessment and/or review/update of the medication profile prior to the start of the certification period, and the registered nurse (RN) and/or licensed practical nurse (LPN) failed to ensure that care was performed/documented as noted above.















































Plan of Correction:

Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator and Nursing department to discuss PA DOH deficiencies from 05/14/2019
Skilled Nursing Services policy to be reviewed and updated as needed by Professional Advisory Committee .
The Administrator will schedule training sessions for all Nurses to provide education in the components of this policy as well as to CMS CoP and State Regulations concerning integration of orders. The DON will complete mandatory in-services with the nursing staff to emphasize the need for coordination of care between members of the care team. This communication be placed in the medical record and/or case conference minutes, and will be monitored by the clinical supervisors responsible to ensure that the communication is taking place and being documented., and that if improvement is not noted, this could result in individual counseling, which could result in termination as they continue through the disciplinary process.
Administrator and Don will audit 100% of patient clinical records and determine areas that require improvement in coordination of care and Integration of orders.
RN's coordination/integration of orders process includes, but is not limited to: the assurance of
the following:

- Timely assessments and submissions of data
- Every patient will be reviewed for coordination of care needs, establishment of care goals, progress and/or barriers reviewed, health status and any continued need for services.
- Medications and treatments orders are to be reviewed and reconciled as needed during each nursing visit, any discrepancies are to be clarified with physician and orders obtained if needed.
- Assure communication with all physicians involved in the plan of care.
- All orders obtained from physician will be added to patient treatment record or medication treatment record, to medication profile and an addendum/update will be made to the plan of treatment. Communications will be put in place for all nurses providing care to patient as well as patient/family regarding changes/updates.
- All medications in patients home will be reviewed to determine if they are compliant with current medication orders.
- Any Medication that is not found in current plan of care will be discussed with MD to determine if an order has been made for this medication, needs to be obtained, has been made by another physician or if medication needs to be discarded.
- Nurses will provide education to Patient/family regarding orders and the need to discard/reorganize all other medications that are not ordered or order/dosages have changed. Nurses are to document patient/family compliance and report to md as needed. Communications with MD are to be placed in patient clinical record.
- Documentation needs to be in place when family administers all medications to patient or if no medications are administered during the time nurse is providing care.
- There must be orders for all medications listed in medication treatment record . All medication orders are to be obtained from physician prior to placing in medication treatment orders.
- Recertification and ROC: Each admitting RN will confirm the schedule of each opening assigned to them, will visit each patient to perform comprehensive m assessment, collect data and will mark on tracking spread sheet that comprehensive assessment was performed within 5 days after the start of care and as required for each type of assessments needed
-
The RN Case Manager is responsible for collaborating with each identified care provider to identify progress and/or barriers to goals and documenting the progress and collaboration in the clinical record.
- Discharge: The RN Case Manager is responsible for communicating the planned discharge date to the other care providers as well as communicating the patient's status at time of discharge
- Integrate orders from all physicians involved in the plan of care and interventions provided to the patient
- Integrate services, whether services are provided directly or under arrangement, to assure the identification of pt needs & factors that could affect pt safety & treatment effectiveness & the coordination of care provided by all disciplines.
- Coordinate care delivery to meet the patient's needs, & involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities.
- Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education & training provided by the HHA, as appropriate, regarding the care & services identified in the plan of care.
Any patient identified as needing improvement in any of the areas mentioned will be scheduled for care coordination conference by 07/13/2019.

Including: (CR #1, 2, 3, 4, 5, 6, and 7).


The RN Case Managers will address coordination of care with nurses as a component of their supervisory visits as the RN Case Manager, Visit Nurse ,Patient, Patient Representative (if any) will be available at the patient's place of residence at the time of the supervisory visits to discuss any items listed above as needed, patient family concerns, assess patient/family understanding of care and compliance. will be discussed.
The Administrator ,Director of Nursing and Quality Management designee will review all records monthly for coordination of care and inclusions of case conference for patients receiving care for more than one certification period. This will occur until there is 100%compliance. Then 20% of patient records will be reviewed quarterly during record reviews and quality management meetings.
Responsible: Administrator
Date of Completion 07/13/2019



Initial Comments:


Based on the findings of an onsite unannounced state re-licensure conducted on May 8, 2019, through May 10, 2019, and May 14, 2019, Elite Home Health Care, Inc. was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.







Plan of Correction:




51.4 (c) LICENSURE
CHANGE IN OWNERSHIP & MANAGEMENT

Name - Component - 00
51.4. Change in ownership; change in management.

(c) A health care facility shall notify the Department in writing within 30 days after a change in management of a health care facility. A change in management occurs when the person responsible for the day to day operation of the health care facility changes.

Observations:


Based upon review of employee personnel files (PF) and interview with agency staff, the agency failed to inform Department of Health (DOH) of change in Director of Nursing and Alternate Director of Nursing, in writing, within thirty (30) days, for two (2) of two (2) PF reviewed, resulting in employment of staff that do not meet the regulatory and agency policy qualifications.

Findings included:

On May 10, 2019, at approximately 11:00 A.M., review of the agency job description titled "Director of Nursing" revealed the following:
"E. Education and Experience: 2. Experience: a. Minimum three (3) years experience in nursing, with at least two (2) years in home health or community health nursing required. b. Minimum one (1) year in a supervisory or management position..."

On May 10, 2019, at approximately 11:00 A.M., review of agency job description titled "Assistant Director of Nursing Trainee" revealed the following:
"E. Education and Experience: 2. Experience: a. experience in nursing, with at least two (2) years in home health or community health required..."

A review of personnel files conducted on May 10, 2019, from approximately 9:30 A.M. to 10:30 A.M. revealed the following:

PF #1, Assistant Director of Nursing Trainee: date of hire April 17, 2019. Pennsylvania State RN license documentation revealed the RN license was issued on April 16, 2019. The employee's application notes graduation from Aria Health School of Nursing in 2019. There was no documentation that the Assistant DON trainee met the qualifications for supervising nurse under 28 Pa. Code, Part IV, Health Facilities, and Subpart G. Chapter 601 and agency policy.

PF #4, Director of Nursing: date of hire September 18, 2018, Pennsylvania State Registered Nurse (RN) license documentation revealed the RN license was issued on August 21, 2018. The employee's resume lists graduation from Aria Health School of Nursing on June 25, 2018. There was no documentation that the DON met the qualifications for supervising nurse under 28 Pa. Code, Part IV, Health Facilities, and Subpart G. Chapter 601 and agency policy.

An interview with the administrator, alternate administrator, assistant director of nursing trainee, and director of operations on May 10, 2019, at approximately 11:30 A.M. confirmed the above findings.
















Plan of Correction:


Meeting held on 05/24/2019 at 5:30 PM between Administrator Assistant Administrator, Nursing and HR departments to discuss deficiencies.
Regulation 51.4. Change in ownership; change in management was reviewed.
Clinical Manager/Director of Nursing and Assistance Director of Nursing and RN Supervisor Job Descriptions to be reviewed and updated as needed by Professional Advisory Committee.
Regulation 51.4. Change in ownership; change in management was reviewed as well
It was decided that Administrator and Co Administrator will assume the positions of DON and ADON until qualified personnel are assigned to these positions. This change in management positions will be documented in minutes and sent to the department of health.
Change to be documented and written documentation is to be sent to the Department in writing within 30 days by the administrator
RN's currently holding these positions will be assigned other qualified RN roles and will be oriented to their Job Description.
- This includes CR#1 and CR#4
To prevent future occurrences, Administrator will cross check Job descriptions with Applicant qualifications before hire.
Administrator is responsible for implementation
Date of Completion 07/13/2019



Initial Comments:


Based on the findings of an onsite unannounced state re-licensure survey conducted on May 8, 2019, through May 10, 2019, and May 14, 2019, Elite Home Health Care, Inc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).







Plan of Correction: