Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey conducted July 27, 2021 and offsite on August 4, 2021, Progressive Health, 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:
601.22(d) REQUIREMENT
CLINICAL RECORD REVIEW
Name - Component - 00
601.22(d) Clinical Record Review. At
least quarterly, appropriate health
professionals, representing at least
the scope of the program, review a
sample of both active and closed
clinical records to assure that
established policies are followed in
providing services (direct as well as
services under arrangement). There is
a continuing review of clinical
records for each 60-day period that a
patient receives home health services
to determine adequacy of the plan of
treatment and appropriateness of
continuation of care.
Observations:
Based on a review of facility documentation, review of policy and procedure, and interview with administrator, the facility failed to ensure at least quarterly, appropriate health professionals, representing at least the scope of the program, review a sample of both active and closed clinical records to determine whether established policies are followed in furnishing services directly or under arrangement.
Findings include:
Review of policy titled, "Clinical Record Maintenance" on August 4, 2021 at approximately 9:45 AM states, "Record Review: Clinical records are systemically reviewed on quarterly basis to assess appropriateness and adequacy of care and services provided as well as to ensure compliance with policies regarding care, delivery, and professional standards of practice. . ."
Agency documents a current unskilled census of one hundred thirty (130) patients.
Review of "Quarterly Record Review" documentation on July 27, 2021 at approximately 10:50 AM for the first and second quarter of 2021 revealed that the agency documented "No patient admission/no data available" for each entry on form.
There was no documentation of any quarterly record reviews for the third or fourth quarter of 2020.
Interview with administrator on July 27, 2021 at approximately 1:30 PM confirmed the above finding.
Plan of Correction:What action will be taken to correct the deficiency as cited?
Agency Administrator/Director of Nursing will ensure that all patient quarterly records are review and documented accordingly. Agency will transfer all non skilled patients currently under the Home health License to the non skilled license to ensure Medicare documentation compliance.
Who is responsible to implement the corrective action?
Director of Nursing.
When will the corrective action be implemented?
Effective immediately
What is the monitoring process we will put into place to ensure implementation and effectiveness of the action plan?
What is the monitoring process we will put into place to ensure implementation and effectiveness of the corrective action?
The Director of Nursing must assure that all patients clinical records are reviewed.
This requirement will be discussed at monthly meetings for the next one month. The pertinent policy and fulfillment of all requirements will be discussed after that time at staff quarterly meetings on an on-going basis to ensure compliance. The professional advisory committee will review these policies concerning patient clinical record review. This will also be discussed quarterly and at their meetings annually to determine if revisions are required. The Director of Nursing will review all patient records at least quarterly during that certification period until 100% compliance. Then 10% of patient records will be reviewed quarterly on an on-going bases to ensure continued compliance. The Director of Nursing will monitor findings and report noncompliance of 10% or more to the quarterly QAPI Committee. The QAPI members will determine what action is required to achieve and maintain 100% compliance. The minutes of QAPI Committee will be discussed at the Professional Advisory Committee yearly meetings. The PAC members will have the opportunity to make further recommendations if appropriate.
601.31(c) REQUIREMENT
PERIODIC REVIEW OF PLAN OF TREATMENT
Name - Component - 00
601.31(c) Periodic Review of Plan of
Treatment. The total plan of
treatment is reviewed by the attending
physician and agency personnel as
often as the severity of the patient's
condition requires, but at least once
every 60 days. Agency professional
staff promptly alert the physician to
any changes that suggest a need to
alter the plan of treatment
Observations:
Based on a review of clinical records (CR), agency policy, and interview with the administrator, it was determined that the agency failed to review and update the plan of care every sixty days for seven (7) of seven (7) CR's reviewed, (CR #1, 2, 3, 4, 5, 6, and 7).
Findings include:
A review of agency policy "Care Plan" on August 4, 2021 at approximately 10:20 AM states, "The total plan of treatment shall be reviewed by the attending physician and the home health agency personnel as often as the severity of the patient's condition requires, but at least once every sixty days...The patient care plan shall be updated as often as the patient condition indicates, but at least once every sixty days..."
A review of CR's was conducted on July 27, 2021, from approximately 10:00 A.M. through 12:00 P.M.
CR #1, Start of Care: 12/21/17, Certification period reviewed 6/21/2021 through 12/21/2021; contained Home Health Certification and Plan of Treatment orders for certification periods of one hundred eighty (180) days. File did not contain any documentation of a care plan update and no review by a physician conducted every sixty (60) days.
CR #2, Start of Care: 11/15/17, Certification period reviewed 5/15/2021 through 11/15/2021; contained Home Health Certification and Plan of Treatment orders for certification periods of one hundred eighty (180) days. File did not contain any documentation of a care plan update and no review by a physician conducted every sixty (60) days.
CR #3, Start of Care: 8/2/15, Certification period reviewed 2/27/2021 through 8/27/2021; contained Home Health Certification and Plan of Treatment orders for certification periods of one hundred eighty (180) days. File did not contain any documentation of a care plan update and no review by a physician conducted every sixty (60) days.
CR #4, Start of Care: 9/9/19, Certification period reviewed 3/9/2021 through 9/9/2021; contained Home Health Certification and Plan of Treatment orders for certification periods of one hundred eighty (180) days. File did not contain any documentation of a care plan update and no review by a physician conducted every sixty (60) days.
CR #5, Start of Care: 12/9/16, Certification period reviewed 6/9/2021 through 12/9/2021; contained Home Health Certification and Plan of Treatment orders for certification periods of one hundred eighty (180) days. File did not contain any documentation of a care plan update and no review by a physician conducted every sixty (60) days.
CR #6, Start of Care: 11/10/18, Discharge Date: 9/1/2020; Certification period reviewed 4/10/2020 through 10/10/2020; contained Home Health Certification and Plan of Treatment orders for certification periods of one hundred eighty (180) days. File did not contain any documentation of a care plan update and no review by a physician conducted every sixty (60) days.
CR #7, Start of Care: 9/1/2020, Discharge Date: 6/30/2021; Certification period reviewed 9/1/2020 through 3/1/2021; contained Home Health Certification and Plan of Treatment orders for certification periods of one hundred eighty (180) days. There was no documentation of a Home Health Certification and Plan of Treatment for a certification period that included the discharge date. File did not contain any documentation of a care plan update and no review by a physician conducted every sixty (60) days.
An interview with the administrator on July 27, 2021 at approximately 1:30 PM confirmed the above findings.
Plan of Correction:What action will be taken to correct the deficiency cited?
Agency Director of Nursing will ensure that all patients records are review and also updated the plan of care every sixty days to ensure compliance.
Agency will ensure that all patients total plan of treatment are reviewed by the attending physician and the Home health agency professional personnel as often as the severity of the patient's condition requires, but at least once every sixty days to ensure compliance.
Agency will ensure that patients care plan are updated as often as the patient condition indicates, but at least once every sixty days to ensure compliance. Agency will transfer all current non skilled patients to our non skill.
Who is responsible to implement the corrective action?
Director of Nursing.
When will the corrective action be implemented?
Effective immediately
What is the monitoring process we will put into place to ensure implementation and effectiveness of the action plan?
The Director of Nursing must assure that all patients receiving care/service from the Agency have physician review and update plan of care at least every sixty days. This requirement will be discussed at monthly meetings for the next one month. The pertinent policy and fulfillment of all requirements will be discussed after that time at staff quarterly meetings on an on-going basis. This will also be discussed at their meetings annually to determine if revisions are required. The Director of Nursing will review all patient records at least every sixty days and ensure the physician plan of treatment is review and updated until 100% compliance. Then 10% of patient records will be reviewed quarterly on an on-going bases to ensure continued compliance. The Director of Nursing will monitor findings and report noncompliance of 10% or more to the quarterly QAPI Committee. The QAPI members will determine what action is required to achieve and maintain 100% compliance. The minutes of QAPI Committee will be discussed at the Professional Advisory Committee yearly meetings. The PAC members will have the opportunity to make further recommendations if appropriate.
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 agency policy, clinical record (CR) reviews, and interview with the administrator, the agency failed to obtain and reconcile the Medication Record with the current Home Health Certification and Plan of Care/physician orders for seven (7) of seven (7) CR's reviewed (CR #1, 2, 3, 4, 5, 6, and 7).
Findings include:
A review of agency policy titled "Medication Profile" conducted on August 4, 2021 at approximately 10:30 AM states, "Medication profiles must be updated at least every sixty days and whenever there is a change in the medication regime..."
A review of CR's was conducted on July 27, 2021 from approximately 10:00 A.M. through 12:00 P.M. revealed the following:
CR #1, Start of Care: 12/21/17, Home Health Certification and Plan of Treatment for certification period reviewed 6/21/2021 through 12/21/2021 states in Section 10. Medications: "see attached medication profile". No medication profile was attached. When asked for current medication profile, agency provided medication profile from start of care date.
CR #2, Start of Care: 11/15/17, Home Health Certification and Plan of Treatment for certification period reviewed 5/15/2021 through 11/15/2021 states in Section 10. Medications: "see attached medication profile". No medication profile was attached. When asked for current medication profile, agency provided medication profile from start of care date.
CR #3, Start of Care: 8/2/15, Home Health Certification and Plan of Treatment for certification period reviewed 2/27/2021 through 8/27/2021 states in Section 10. Medications: "see attached medication profile". No medication profile was attached. When asked for current medication profile, agency provided medication profile from start of care date.
CR #4, Start of Care: 9/9/19, Home Health Certification and Plan of Treatment for certification period reviewed 3/9/2021 through 9/9/2021 states in Section 10. Medications: "see attached medication profile". No medication profile was attached. When asked for current medication profile, agency provided medication profile from start of care date.
CR #5, Start of Care: 12/9/16, Home Health Certification and Plan of Treatment for certification period reviewed 6/9/2021 through 12/9/2021 states in Section 10. Medications: "see attached medication profile". No medication profile was attached. When asked for current medication profile, agency provided medication profile from start of care date.
CR #6, Start of Care: 11/10/18, Home Health Certification and Plan of Treatment for certification period reviewed 4/10/2020 through 10/10/2020 states in Section 10. Medications: "see attached medication profile". No medication profile was attached. When asked for current medication profile, agency provided medication profile from start of care date.
CR #7, Start of Care: 9/1/2020, Home Health Certification and Plan of Treatment for certification period reviewed 9/1/2020 through 3/1/2021 states in Section 10. Medications: "see attached medication profile". No medication profile was attached. When asked for current medication profile, agency provided medication profile from start of care date.
An interview with the administrator conducted on July 27, 2021 at approximately 1:30 P.M. confirmed the above findings.
Plan of Correction:What action will be taken to correct the deficiency cited?
Agency Director of Nursing will obtain and reconcile all patients Medication Record or profile. The Director of Nursing will ensure that a patients medication profile are review and updated with the Physician to ensure compliance. The Director of Nursing will ensure Plan of Care/physician orders updated at Physician visits, when medication change to ensure compliance.
Agency will ensure that all patients
Medication profiles are updated at least every sixty days and whenever there is a change in the medication regime to ensure compliance.
Agency will transfer all non skilled patients currently under the Home health License to our non skilled Home care License to ensure compliance.
Who is responsible to implement the corrective action?
Director of Nursing.
When will the corrective action be implemented?
Effective immediately
What is the monitoring process we will put into place to ensure implementation and effectiveness of the action plan?
The Director of Nursing must assure that all patients receiving care/service medication profile are review and updated accordingly to ensure compliance. This requirement will be discussed at monthly meetings for the next one month. The pertinent policy and fulfillment of all requirements will be discussed after that time at staff quarterly meetings on an on-going basis. This will also be discussed at their meetings annually to determine if revisions are required. The Director of Nursing will review and update all patient medication profile at least monthly until 100% compliance. Then 10% of patient records will be reviewed quarterly on an on-going bases to ensure continued compliance. The Director of Nursing will monitor findings and report noncompliance of 10% or more to the quarterly QAPI Committee. The QAPI members will determine what action is required to achieve and maintain 100% compliance. The minutes of QAPI Committee will be discussed at the Professional Advisory Committee yearly meetings. The PAC members will have the opportunity to make further recommendations if appropriate.
601.35(a) REQUIREMENT
SELECTION OF AIDES
Name - Component - 00
601.35(a) Selection of Aides. Home
health aides are selected on the basis
of such factors as sympathetic
attitude toward the care of the sick,
ability to read, write, and carry out
directions, and maturity and ability
to deal effectively with the demands
of the job. Aides are carefully
trained in assisting patients to
achieve maximum self-reliance,
principles of nutrition and meal
preparation, the aging process and
emotional problems of illness,
maintaining a clean, healthful, and
pleasant environment, changes in
patient's condition that should be
reported, work of the agency and the
health team, ethics and
confidentiality, and recordkeeping.
Home Health Aid Training. All home
health aides have completed a minimum
of 60 hours of classroom instruction
prior to or during the first 3 months
of employment.
They are closely supervised to assure
their competence in providing care.
Observations:
Based on a review of personnel files (PF), a review of agency policy, and an interview with the administrator, the agency failed to ensure that the home health aides had evidence of the required mandated training for seven (7) of eight (8) PF reviewed. (PF #1, 3, 4, 5, 6, 7, and 8).
Findings Include:
Review of agency policy was conducted on August 4, 2021, at approximately 12:00. Policy "STAFF TRAINING AND EDUCATIONAL IN-SERVICES POLICY" states, "Policy: The Progressive Health Inc provides comprehensive orientation, educational programs, and continuing education for all employees in order to promote self-development. education is fostered through orientation and through continuous supervision which includes formal job performance evaluations (conducted three months after hire and annually) for all staff and competency evaluations for all Field Staff conducted at orientation and annually. In the case of competency evaluation, if areas of improvement are noted, specific additional training is provided..."
Agency does not have a policy that specifically states number of training hours needed for Home Health Aides.
Review of personnel files was conducted on July 27, 2021, from approximately 11:15 A.M. to 12:20 P.M.
1. PF #1, Date of Hire: 11/9/18, revealed no evidence of the required 60 hour training prior to or within 3 months of the date of hire.
2. PF #3, Date of Hire: 10/16/19, revealed no evidence of the required 60 hour training prior to or within 3 months of the date of hire.
3. PF #4, Date of Hire: 3/3/2020, revealed no evidence of the required 60 hour training prior to or within 3 months of the date of hire.
4. PF #5, Date of Hire: 12/15/16, revealed no evidence of the required 60 hour training prior to or within 3 months of the date of hire.
5. PF #6, Date of Hire: 1/28/19, revealed no evidence of the required 60 hour training prior to or within 3 months of the date of hire.
6. PF #7, Date of Hire: 8/19/16, revealed no evidence of the required 60 hour training prior to or within 3 months of the date of hire.
7. PF #8, Date of Hire: 9/7/19, revealed no evidence of the required 60 hour training prior to or within 3 months of the date of hire.
Interview with the administrator on July 27, 2021 at approximately 1:30 P.M. confirmed that the above findings.
Plan of Correction:Agency Administrator will ensure that all hire Home health Aides had evidence of required mandated training at hire and annually on employee files to ensure compliance. This is to promote self development among Agency employees.
Agency will ensure that all hire employees completed this training
three months after hire and annually. The training will be conducted for all staff and competency evaluations for all Field Staff conducted at orientation and annually to ensure compliance.
Agency will ensure that policy that specifically states number of training hours needed for Home Health Aides is updated and in place to ensure compliance. All training materials and attendees will be documented and noted on employees file.
Who is responsible to implement the corrective action?
Administrator.
When will the corrective action be implemented?
Effective immediately
What is the monitoring process we will put into place to ensure implementation and effectiveness of the action plan?
The Administrator must assure that all Policies and procedure is clear and specific. The Administrator will review and update specifically states number of training hours needed for Home health Aide is in place.
This requirement will be discussed at monthly meetings for the next one month. The pertinent policy and fulfillment of all requirements will be discussed after that time at staff quarterly meetings on an on-going basis. The professional advisory committee will review and update these policies concerning states required number of hours needed for Home health Aide and ensure is documented and in place. This will also be discussed at their meetings annually to determine if revisions are required. The Administrator will review and update this policy and procedures until 100% compliance. Then 10% of patient records will be reviewed quarterly on an on-going bases to ensure continued compliance. The Administrator will monitor findings and report noncompliance of 10% or more to the quarterly QAPI Committee. The QAPI members will determine what action is required to achieve and maintain 100% compliance. The minutes of QAPI Committee will be discussed at the Professional Advisory Committee yearly meetings. The PAC members will have the opportunity to make further recommendations if appropriate.
601.36(a) REQUIREMENT
MAINTENANCE AND CONTENT OF RECORD
Name - Component - 00
601.36(a) Maintenance and Content of
Record. A clinical record is
maintained in accordance with accepted
professional standards and contains:
(i) pertinent past and current
findings,
(ii) plan of treatment,
(iii) appropriate identifying
information,
(iv) name of physician,
(v) drug, dietary, treatment and
activity orders,
(vi) signed and dated clinical
progress notes (clinical notes are
written the day service is rendered
and incorporated no less often than
weekly),
(vii) copies of summary reports sent
to the physician, and
(viii) a discharge summary.
Observations:
Based on a review of clinical records (CR), agency policy, and an interview with the administrator, the agency failed to maintain the clinical record in accordance with accepted professional standards for seven (7) of seven (7) CR's reviewed, (CR #1, 2, 3, 4, 5, 6, and 7).
Findings include:
A review of agency policy titled "Clinical Record Contents" on August 4, 2021, at approximately 11:00 AM states, "The clinical record includes the following information:...copies of summary reports sent to physicians...discharge summary...Discharge Summary: A discharge summary is to be completed on all patients/clients discharged from the Agency. It is to be completed within thirty days of discharge..."
A review of agency policy titled "Physician Responsibilities" on August 4 2021 at approximately 11:30 AM states, "The physician will receive periodic updates from the Agency regarding the patient's condition and any changes observed by the clinicians..."
A review of clinical records was conducted on July 27, 2021, from approximately 10:00 A.M. through 12:00 P.M.
CR #1; Start of Care: 12/21/17; Certification period reviewed: 6/21/2021 through 12/21/2021; revealed no documentation that a 60 day summary had been sent to the physician for any 60 day period since the start of care date.
CR #2; Start of Care: 11/15/17; Certification period reviewed: 5/15/2021 through 11/15/2021; revealed no documentation that a 60 day summary had been sent to the physician for any 60 day period since the start of care date.
CR #3; Start of Care: 8/2/15; Certification period reviewed: 2/27/2021 through 8/27/2021; revealed no documentation that a 60 day summary had been sent to the physician for any 60 day period since the start of care date.
CR #4; Start of Care: 9/19/19; Certification period reviewed: 3/9/2021 through 9/9/2021; revealed no documentation that a 60 day summary had been sent to the physician for any 60 day period since the start of care date.
CR #5; Start of Care: 12/9/16; Certification period reviewed: 6/9/2021 through 12/9/2021; revealed no documentation that a 60 day summary had been sent to the physician for any 60 day period since the start of care date.
CR #6; Start of Care: 11/10/18; Discharge Date: 9/1/2020; Certification period reviewed: 4/10/2020 through 10/10/2020; revealed no documentation that a 60 day summary had been sent to the physician for any 60 day period since the start of care date and did not contain any documentation of a discharge summary.
CR #7; Start of Care: 9/1/2020; Discharge Date: 6/30/2021; Certification period reviewed: 9/1/2020 through 3/1/2021; revealed no documentation that a 60 day summary had been sent to the physician for any 60 day period since the start of care date and did not contain any documentation of a discharge summary.
An interview with the administrator on July 27, 2021, at approximately 1:30 pm confirmed the above findings.
Plan of Correction:What action will be taken to correct the deficiency cited?
Agency Director of Nursing will maintain all clinical record in accordance with accepted professional standards to ensure compliance.
Agency will ensure that all clinical record including the following information: copies of summary reports sent to physicians, discharge summary
is completed on all patients/clients discharged from the Agency to ensure compliance. Agency will ensure that it completed all summary within thirty days of discharge to ensure compliance. Agency will ensure that patients discharge summary, 60 days summary are sent to the attending physician and documented to ensure compliance.
Who is responsible to implement the corrective action?
Director of Nursing.
When will the corrective action be implemented?
Effective immediately
What is the monitoring process we will put into place to ensure implementation and effectiveness of the action plan?
The Director of Nursing must assure that all patients clinical record contents are maintain in accordance with accepted professional standards. The pertinent policy and fulfillment of all requirements will be discussed after that time at staff quarterly meetings on an on-going basis. The professional advisory committee will review these policies concerning clinical record contents to ensure that they are maintain in accordance with professional standards. This will also be discussed at their meetings annually to determine if revisions are required. The Director of Nursing will review and maintain all patient clinical record in a professional standards until 100% compliance. Then 10% of patient records will be reviewed quarterly on an on-going bases to ensure continued compliance. The Director of Nursing will monitor findings and report noncompliance of 10% or more to the quarterly QAPI Committee. The QAPI members will determine what action is required to achieve and maintain 100% compliance. The minutes of QAPI Committee will be discussed at the Professional Advisory Committee twice yearly meetings. The PAC members will have the opportunity to make further recommendations if appropriate.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on July 27, 2021, Progressive Health, Inc., was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on July 27, 2021, Progressive Health, Inc., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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