Initial Comments:
An onsite follow-up survey completed March 8, 2024, found that Providence Home Health Agency, Inc. had corrected the following deficiencies cited under the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies. The deficiencies were cited as a result of a federal recertification survey completed on January 24, 2024. As a result of the survey, the condition cited at: 484.65 Quality Assessment/Performance Improvement was lifted by verification of implementation of the approved plan of correction. Standard level deficiencies remain.
Plan of Correction:
484.55(b)(3) ELEMENT Therapy services determine eligibility Name - Component - 00 When physical therapy, speech-language pathology, or occupational therapy is the only service ordered by the physician or allowed practitioner, a physical therapist, speech-language pathologist or occupational therapist may complete the comprehensive assessment, and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. The occupational therapist may complete the comprehensive assessment if the need for occupational therapy establishes program eligibility.
Observations:
Based on a review of the agency plan of correction and an interview with the agency alternate Administrator, the agency failed to ensure new orders were sent to the Physician for clinical record #2, an audit was conducted of clinical records, and a review was conducted weekly of 25% of client charts, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/08/2024 at approximately 9:30 a.m., approved by the Department on 03/04/2024, revealed the following:
"......... For Cr#2 (clinical record #2) new orders will be sent to the Physician. ....... The agency will conduct an audit of clinical records to ensure the deficient practices does not reoccur. ....... The Don (Director of Nursing) will review 25% of client charts weekly ...."
Corrective action date: 02/29/2024.
Documentation review #1: No documentation provided of obtaining new Physician orders for clinical record #2, an audit being conducted of the clinical records, and a review being conducted weekly of 25% of client charts.
An interview conducted on March 8, 2024 at approximately 11:30 a.m. with the agency alternate Administrator confirmed the above findings.
Plan of Correction:New Physician orders for clinical record #2 will be obtained. The Don (Director of Nursing) will review 25% of client charts weekly. Audit of All clinical records.
484.55(c)(5) ELEMENT A review of all current medications Name - Component - 00 A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.
Observations:
Based on a review of the agency plan of correction and an interview with the agency alternate Administrator, the agency failed to ensure the Director of Nursing reviewed all charts, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/08/2024 at approximately 9:30 a.m., approved by the Department on 03/04/2024, revealed the following:
"...... DON (Director of Nursing) to review all charts ......."
Corrective action date: 02/29/2024.
Documentation review #1: No documentation provided of the Director of Nursing reviewed all charts.
An interview conducted on March 8, 2024 at approximately 11:30 a.m. with the agency alternate Administrator confirmed the above findings.
Plan of Correction:DON to review all charts to ensure have been reconciled.
Initial Comments:An onsite follow-up survey completed on March 8, 2024 found that Providence Home Health Agency, Inc. had corrected the deficiencies cited under the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness. The deficiencies were cited as a result of a federal recertification survey completed January 24, 2024. Plan of Correction:
Initial Comments:
An onsite follow-up survey completed on March 8, 2024 found that Providence Home Health Agency, Inc. had not corrected the deficiencies cited under the requirements of 28 Pa. Code, Part IV, Health Facilities, Subpart G. Chapter 601. The deficiencies were cited as a result of a state relicensure survey completed January 24, 2024.
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 the agency plan of correction and an interview with the agency alternate Administrator, the agency failed to obtain all federal and state background checks on EF#2 (employee #2) and EF#9 (employee #9), as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/08/2024 at approximately 9:30 a.m., approved by the Department on 03/04/2024, revealed the following:
" ........ HR (Human Resources) will obtain all federal and state background checks on EF#2, EF#9 and maintain the background checking in the employee's files ....."
Corrective action date: 03/04/2024.
Documentation review #1: No documentation provided of obtaining a federal criminal history report for EF#2 (employee #2) nor a Childline criminal history report for EF#9 (employee #9).
An interview conducted on March 8, 2024 at approximately 11:30 a.m. with the agency alternate Administrator confirmed the above findings.
Plan of Correction:HR will obtain all federal and state background checks on EF#2, EF#9 and maintain the background checking in the employee's files.
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 the agency plan of correction and an interview with the agency alternate Administrator, the agency failed to obtain employees applicable CPR (cardio pulmonary resuscitation) training, Orientation, and TB (tuberculosis) testing, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/08/2024 at approximately 9:30 a.m., approved by the Department on 03/04/2024, revealed the following:
".... All Employees will obtain applicable ........ , CPR, Orientation, and TB testing. ........."
Corrective action date: 03/04/2024.
Documentation review #1: No documentation provided of employee #2, #5, #6, and #8 obtaining Orientation (utilizing the Orientation Checklist per policy) nor TB testing. No documentation provided of employee #6 obtaining CPR certification.
An interview conducted on March 8, 2024 at approximately 11:30 a.m. with the agency alternate Administrator confirmed the above findings.
Plan of Correction:Will provide update Documentation for #1: No documentation provided of employee #2, #5, #6, and #8 obtaining Orientation (utilizing the Orientation Checklist per policy) nor TB testing. No documentation provided of employee #6 obtaining CPR certification.
601.31(a) REQUIREMENT PATIENT ACCEPTANCE Name - Component - 00 601.31(a) Patient Acceptance. Patients are accepted for treatment on the basis of a reasonable expectation that the patient's medical, nursing and social needs can be met adequately by the agency in the patient's place of residence. Care follows a written plan of treatment established and periodically reviewed by a physician and care continues under the general supervision of a physician.
Observations:
Based on a review of the agency plan of correction and an interview with the agency alternate Administrator, the agency failed to ensure the Medical Social Worker was re-educated on following MD (doctor of medicine) orders and failed to ensure the clients charts were monitored weekly, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/08/2024 at approximately 9:30 a.m., approved by the Department on 03/01/2024, revealed the following:
" ......... The agency will re-educate .......... Medical social worker on following MD orders for frequency and notifying the physician of any changes to the POC frequency...... The DON and Compliance officer will monitor the client's charts weekly for compliance with the physician's POC frequencies. ......"
Corrective action date: 03/04/2024.
Documentation review #1: No documentation provided of re-educating the Medical Social Worker on following MD orders for nor of the DON (Director of Nursing) and the Compliance officer monitoring the client's charts weekly for compliance.
An interview conducted on March 8, 2024 at approximately 11:30 a.m. with the agency alternate Administrator confirmed the above findings.
Plan of Correction: The agency will re-educate the Medical social worker on following MD orders for frequency and notifying the physician of any changes to the POC frequency. The DON and Compliance officer will monitor the client's charts weekly for compliance with the physician's POC frequencies.
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 a review of the agency plan of correction and an interview with the agency alternate Administrator, the agency failed to ensure a weekly review of client records was conducted, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/08/2024 at approximately 9:30 a.m., approved by the Department on 03/04/2024, revealed the following:
" ..... The Agency DON (Director of Nursing) will review Client records weekly. ....."
Corrective action date: 03/04/2024.
Documentation review #1: No documentation provided of the agency DON reviewing the Client records weekly.
An interview conducted on March 8, 2024 at approximately 11:30 a.m. with the agency alternate Administrator confirmed the above findings.
Plan of Correction:Agency will Provide documentation provided of the agency DON reviewing the Client records weekly.
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 a review of the agency plan of correction and an interview with the agency alternate Administrator, the agency failed to ensure all client charts were reviewed weekly, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/08/2024 at approximately 9:30 a.m., approved by the Department on 02/20/2024, revealed the following:
" ....... All charts will be reviewed weekly......."
Corrective action date: 03/04/2024.
Documentation review #1: No documentation provided of all client charts being reviewed weekly.
An interview conducted on March 8, 2024 at approximately 11:30 a.m. with the agency alternate Administrator confirmed the above findings.
Plan of Correction:The Agency DON (Director of Nursing) will review Client records weekly.
|