QA Investigation Results

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


There are  11 surveys for this facility. Please select a date to view the survey results.

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



Initial Comments:


Based on the findings of an onsite unannounced complaint investigation survey conducted July 11, 2018, and completed July 16, 2018, Elite Home Health Care was identified to have the following standard level deficiency that was determined to be in substantial compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.









Plan of Correction:




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

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

Observations:


Based on review of patient files, agency policies, complaint/call logs, and interview with the Director, it was determined that the agency failed to provide services ordered by the physician as indicated in the plan of care, for one, (1), of three, (30, Patient files, (PF), reviewed. (PF #1).

Findings Include:

On July 11, 2018, at approximately 11:00 a.m., a review of agency policy entitled, " Process & Procedures for Calling Out", revealed that, " It is mandatory that to call the office 2 hours before your scheduled time. If the office is closed please leave a message on the answering machine. It is recommended that you call back during normal business hours to confirm that the message has been received and your supervisor is aware " .
On July 11, 2018 at approximately 11:30 a.m., a review of PF #1's " Home Health Certification Plan of Care, from May 21, 2018 thru July 19, 2018, revealed that it was signed by Physician. Further review revealed that the patient was born on December 18, 2004, (age 14), with a primary diagnosis of, Severe Hypoxic Ischemia Encephalopathy, (brain damage caused by oxygen loss.), Cortical Blindness, (loss of vision in a normal-appearing eye caused by damage to the brain's occipital cortex.), and diseases of the Digestive System. She is on Seizure, (a short episode of symptoms caused by a burst of abnormal electrical activity in the brain.), precautions, fall precautions, incontinent of bowel and bladder, wheelchair bound. Orders were for skilled nursing eight (8) hours overnight.
Continued review of PF #1's file, revealed that skilled nursing services primarily included: Assess all body systems; Vital signs every shift; Administer and monitor Gastric tube, (G-Tube), feedings; Maintain patent airway, (open airway), during Seizure activity; Continuous Pulse Ox, (a meter placed on the finger to measure blood oxygen); VNS, (Vagus Nerve Stimulation), Protocol, (a process used to control seizure activity.); Suction nasal and oral secretions via a 10 FR catheter, (a plastic tube connected to a suction machine).
Review of PF #1's filed progress note revealed no documentation or evidence that a skilled nurse had been present in the home on June 7, 2018. There was no evidence that an alternate nurse had reported for the 10:00 p.m. to 6:00 a.m. shift on June 7, 2018.
On July 11, 2018 at approximately 12:00 a.m. a review of the complaint logs revealed that on May 17, 2018 at 2:00 p.m., PF #1's mother called the agency to report the scheduled nurse did not, show up or call out " . The agency ' s response was to " take the no show LPN off the rotation, and add two LPN ' s to the case. Two LPN ' s met with mom " , before the start of shift on May 23, 2018.
On July 11, 2018 at approximately 12:10 p.m., review of PF #1's file and the compliant log revealed that services ordered by the physician in the plan of care were not carried out on May 17, 2018 and June 7, 2018.
On July 11, 2018 at approximately 3:10 p.m., in an interview conducted with the Director Operations for the Pediatric Division. After questioning it was revealed that the patient's plan of care was effective, " only on Tuesdays and Thursdays " . It was confirmed that the plan of care lacked this clarification. It was confirmed that the agency failed to follow the Physician orders and certified plan of care on Thursday, May 17, 2018, and on Thursday, June 7, 2018.











Plan of Correction:

Meeting held with the Director of Nursing and the Director of operations on 7/30/2018 to review last survey from the Department of Health of 07/16/2018 regarding the call out policy and it was determined that policy needed to be updated to include the phone numbers for the director of operations and the nursing supervisor for all call outs made while the office is closed to ensure all calls are received and actions can be taken to provide services as ordered. Updated policy will be provided to all employees.
Director of Nursing, the Director of operations and Nursing supervisors will be evaluated on this
area by the administrator during the next quarterly review.
Correction Date 08/23/2018
Administrator is responsible for implementing plan of care correction and will ensure compliance
Meeting held with the Director of Nursing and the Director of operations on 7/30/2018 to review last survey from the Department of Health of 07/16/2018 regarding Physician's orders and the certified plan of care. The Plan of care and physicians orders policy was reviewed at this time.
Admitting RN is to be responsible for creating a plan of care according to Physicians orders.
This plan of care will state specific times and frequency of services to be provided ,hours per
day , days of the week as well as specific times of the day if so ordered by the primary physician. All active patient plan of care will be checked. If any 485 that is not clear regarding specific schedule/hours/frequency ordered, A 486 addendum will be created and sent to the physician for certification and signature. During the re certification process all 485's will be
checked for accuracy and updates, if any.
All schedules are to be reviewed and confirmed with the nurse and the patient/ family whenever there is a change in schedule, or agency provided care given. All efforts must be made to staff
the patient as ordered in the plan of care. Evidence of communications and Services provided will be kept in patient file.
Documentation is to be kept regarding call outs, attempts made to cover any shift as well as reports of any break in Service provision, complaints of non-coverage and noncompliance with
the plan of care.
Director of Nursing, the Director of operations and Nursing supervisors will be evaluated on this
area by the administrator monthly until 100% compliance is achieved and during quarterly reviews thereafter.
Correction Date 08/23/2018
Administrator is responsible for implementing plan of care correction and will ensure compliance.


Initial Comments:


Based on the findings of an onsite unannounced complaint survey conducted on July 11, 2018, and completed July 16, 2018, Elite Home Health Care was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.





Plan of Correction:




Initial Comments:



Based on the findings of an onsite unannounced complaint investigation survey conducted July 11, 2018 and completed July 16, 2018, Elite Home Health Care was found not to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.








Plan of Correction:




601.32 REQUIREMENT
SKILLED NURSING SERVICE

Name - Component - 00
601.32 V. SKILLED NURSING SERVICE.


Observations:


Based on review of patient files, agency policies, complaint/call logs, and interview with the Director, it was determined that the agency failed to provide services ordered by the physician as indicated in the plan of care, for one, (1), of three, (30, Patient files, (PF), reviewed. (PF #1).

Findings Include:

On July 11, 2018, at approximately 11:00 a.m., a review of agency policy entitled, " Process & Procedures for Calling Out", revealed that, " It is mandatory that to call the office 2 hours before your scheduled time. If the office is closed please leave a message on the answering machine. It is recommended that you call back during normal business hours to confirm that the message has been received and your supervisor is aware " .
On July 11, 2018 at approximately 11:30 a.m., a review of PF #1's " Home Health Certification Plan of Care, from May 21, 2018 thru July 19, 2018, revealed that it was signed by Physician. Further review revealed that the patient was born on December 18, 2004, (age 14), with a primary diagnosis of, Severe Hypoxic Ischemia Encephalopathy, (brain damage caused by oxygen loss.), Cortical Blindness, (loss of vision in a normal-appearing eye caused by damage to the brain's occipital cortex.), and diseases of the Digestive System. She is on Seizure, (a short episode of symptoms caused by a burst of abnormal electrical activity in the brain.), precautions, fall precautions, incontinent of bowel and bladder, wheelchair bound. Orders were for skilled nursing eight (8) hours overnight.
Continued review of PF #1's file, revealed that skilled nursing services primarily included: Assess all body systems; Vital signs every shift; Administer and monitor Gastric tube, (G-Tube), feedings; Maintain patent airway, (open airway), during Seizure activity; Continuous Pulse Ox, (a meter placed on the finger to measure blood oxygen); VNS, (Vagus Nerve Stimulation), Protocol, (a process used to control seizure activity.); Suction nasal and oral secretions via a 10 FR catheter, (a plastic tube connected to a suction machine).
Review of PF #1's filed progress note revealed no documentation or evidence that a skilled nurse had been present in the home on June 7, 2018. There was no evidence that an alternate nurse had reported for the 10:00 p.m. to 6:00 a.m. shift on June 7, 2018.
On July 11, 2018 at approximately 12:00 a.m. a review of the complaint logs revealed that on May 17, 2018 at 2:00 p.m., PF #1's mother called the agency to report the scheduled nurse did not, show up or call out " . The agency ' s response was to " take the no show LPN off the rotation, and add two LPN ' s to the case. Two LPN ' s met with mom " before the start of shift on May 23, 2018.
On July 11, 2018 at approximately 12:10 p.m., review of PF #1's file and the compliant log revealed that services ordered by the physician in the plan of care were not carried out on May 17, 2018 and June 7, 2018.
On July 11, 2018 at approximately 3:10 p.m., in an interview conducted with the Director Operations for the Pediatric Division. After questioning it was revealed that the patient's plan of care was effective, " only on Tuesdays and Thursdays " . It was confirmed that the plan of care lacked this clarification. It was confirmed that the agency failed to follow the Physician orders and certified plan of care on Thursday, May 17, 2018, and on Thursday, June 7, 2018.








Plan of Correction:

Meeting held with the Director of Nursing and the Director of operations on 7/30/2018 to review last survey from the Department of Health of 07/16/2018 regarding the call out policy and it was determined that policy needed to be updated to include the phone numbers for the director of operations and the nursing supervisor for all call outs made while the office is closed to ensure all calls are received and actions can be taken to provide services as ordered. Updated policy will be provided to all employees.
Director of Nursing, the Director of operations and Nursing supervisors will be evaluated on this
area by the administrator during the next quarterly review.
Correction Date 08/23/2018
Administrator is responsible for implementing plan of care correction and will ensure compliance
Meeting held with the Director of Nursing and the Director of operations on 7/30/2018 to review last survey from the Department of Health of 07/16/2018 regarding Physician's orders and the certified plan of care. The Plan of care and physicians orders policy was reviewed at this time.
Admitting RN is to be responsible for creating a plan of care according to Physicians orders.
This plan of care will state specific times and frequency of services to be provided ,hours per
day , days of the week as well as specific times of the day if so ordered by the primary physician. All active patient plan of care will be checked. If any 485 that is not clear regarding specific schedule/hours/frequency ordered, A 486 addendum will be created and sent to the physician for certification and signature. During the re certification process all 485's will be
checked for accuracy and updates, if any.
All schedules are to be reviewed and confirmed with the nurse and the patient/ family whenever there is a change in schedule, or agency provided care given. All efforts must be made to staff the patient as ordered in the plan of care. Evidence of communications and Services provided will be kept in patient file.
Documentation is to be kept regarding call outs, attempts made to cover any shift as well as reports of any break in Service provision, complaints of non-coverage and noncompliance with
the plan of care.
Director of Nursing, the Director of operations and Nursing supervisors will be evaluated on this
area by the administrator monthly until 100% compliance is achieved and during quarterly reviews thereafter.
Correction Date 08/23/2018
Administrator is responsible for implementing plan of care correction and will ensure compliance.


Initial Comments:


Based on the findings of an onsite unannounced complaint investigation survey conducted July 11, 2018 and completed July 16, 2018, Elite Home Health Care was found to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.





Plan of Correction:




Initial Comments:


Based on the findings of an onsite unannounced complaint investigation survey completed on July 11, 2018 and July 16, 2018, Elite Home Health Care, was found not to be in compliance with the following requirement(s) of 35 P.S. 448.809 (b).


Where is the citation tag? Copy/paste from Ch 51 then delete




Plan of Correction:




35 P. S. 448.809b LICENSURE
Photo Id Reg

Name - Component - 00
(1) The photo identification tag shall include a recent photograph of the employee, the employee's name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.



Observations:


Based on observation, review of agency policy and interview with the administrator, the facility failed to follow the agency's personnel policy regarding identification badges for six, (6) of seven, (7), office and administrative personnel observed.

Findings include:

Review of agency policy entitled, "Employee Identification Badge", on July 11, 2018, it was revealed that, Supervisors shall ensure that all employees wear Identification badges while on duty. Employees shall also wear their identification badges when they are: representing the agency in a professional capacity, and networking with other professionals."

On July 11, 2018 at approximately 10:30 a.m., this surveyor observed approximately six (6) employees without ID Badges. Three unidentified employees were working at the front desk, while three employees working directly with the surveyor did not carry an ID badge.

In an interview with the Director on July 11, 2018 at approximately 3:10 p.m., it was confirmed that ID badges where not being worn. The office and administrative personnel put on their badges.





Plan of Correction:

Meeting held with the Director of Nursing and the Director of operations on 7/30/2018 to review last survey from the Department of Health of 07/16/2018 regarding employee ID Policy the Director of operations is responsible for advising staff/Office Holders on the contents of this policy.
Director of Operations will responsible for the issue, the enforcement of wearing photo
identification badges for all employees, and disciplinary actions for those who are non-compliant with this policy. Random supervisory home visits will be performed to evaluate
and demonstrate compliance.
Director of Operations will be evaluated on this area by the administrator monthly until 100%
compliance is achieved and during quarterly reviews after that.
Correction Date 08/23/2018 Director of operations is responsible for implementing plan of care correction and will ensure compliance.