Initial Comments:
Based on the findings of an onsite unannounced home health agency complaint investigation initiated on November 18, 2025, November 19 through 21, 2025, and completed November 24, 2025, Faithful Nursing, LP Home Care was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health facilities, Subpart F. Chapter 601.
Plan of Correction:
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 review of policy/procedures, personnel files (PF), and interview with agency Administrator and Assistant Administrator agency failed to ensure the Clinical Manager provided evaluation of the clinical competence of nursing personnel and their performance in delivery of services for one (1) of three (3) PFs reviewed. PF #1.
Findings included:
Review of policy 12.0 Skilled Nursing Services, "The clinical Manager/RN clinical case manager role is to: Function as the immediate supervisor to the nursing staff and to provide for the evaluation of the clinical competence of nursing personnel and their performance in delivery of services to patients and families."
PF review completed November 18, 2025 between approximately 10:00 AM and 1:00 PM revealed the following:
PF #1, Date of Hire (DOH), 8/15/2018: Initial competency assessment for care of patient with tracheostomy 8/11/2018 and annual competency 9/21/2021. Annual competency for 11/19/2019 and 10/13/2022 did not contain ventilator/tracheostomy care. Annual competencies for years 2023-2025 did not contain any skills assessment. Case study for 2025 annual competency incomplete. Understanding of plan of care/485 and documentation requirements partially met. No competency on care of patient with nephrostomy tubes.
Interview completed with agency Administrator and Assistant Administrator completed November 18, 2025 at approximately 1:30 PM confirmed the above findings.
Plan of Correction:An approved Plan of Correction is not on file.
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 policies/procedures, clinical records (CR), and interviews with agency administrator and assistant administrator agency failed to ensure plan of treatment was specific to diagnoses from recent hospitalization for one (1) of three (3) CRs reviewed. CR #1, CR #2, and CR #3.
Findings include:
Review of policy A-11.0: Conformance with Physician Orders: plan of care completed October 27, 2025 revealed, "Faithful Nursing will review and revise plan of care regularly as the patient's condition requires at least every 60 days."
CR review completed November 18, 2025 between 10:00 AM and 1:00 PM revealed the following:
CR #1, Start of Care (SOC) 10/2/2019; certification period: 10/30/2025-12/28/2025; Physician's orders: "Skilled nursing to provide up to 70 hours weekly for the next 60 days. Skilled nurse to complete a head to toe assessment each visit to include: Temperature, blood pressure, heart rate, respirations, and oxygen saturation level. Report any vitals outside parameters to the physician."
No documentation of updated plan of care due to nephrostomy tube placement during most recent hospitalization.
CR #2, SOC: 5/15/2020; certification period: 10/30/2025-12/28/2025; Physician's orders: "Skilled nursing to be provided up to 128 hours a week. Skilled nursing to complete a head to toe assessment every visit to include vital signs: Temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation levels. Skilled nurse to report any vitals outside of parameters to the physician and case manager."
No documentation of ventilator ventilator use or settings. head to toe assessment, no documentation of oxygen saturation.
CR #3, SOC: 4/22/2020; certification period 9/23/2025-11/21/2025; Physician's orders: "Skilled nursing to provide services up to 13 hours a week for the next 60 days. Skilled nurse to complete a head to toe assessment every visit to include vital signs: Temperature, blood pressure, respiratory rate, heart rate and to report any vital signs outside of parameter to the physician and case manager. Notify physician of oxygen saturation < 90% lasting > than 3 minutes or any difficulty breathing."
No documentation of oxygen saturation.
Interview completed with agency Administrator and Assistant Administrator completed November 18, 2025 at approximately 1:30 PM confirmed the above findings.
Plan of Correction:An approved Plan of Correction is not on file.
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 reviews of policy/procedures, clinical records (CR), and interview with agency Administrator and Assistant Administrator the agency failed to ensure the plan of treatment was updated with each change in patient condition but not later than at least once every 60 days for one (1) of three (3) clinical records reviewed. CR #1.
Findings include:
Review of policy C-2.0 Acceptance of Patients, Plan of Treatment/Care and Medical Supervision completed November 24, 2025 at approximately 2:00 PM revealed, "The total plan of treatment/care is reviewed by the attending physician and the agency's Clinical RN case manager or designee at the following times: as often as severity of the patient's condition requires; at least once every sixty (60) days."
Medical record review completed November 18, 2025 between approximately 10:00 AM and 1:00 PM revealed the following:
MR #1, Start of Care (SOC): 10/2/2019; certification period: 10/30/2025-12/28/2025; No documentation on plan of care patient had bilateral nephrostomy tubes placed.
Interview completed with agency Administrator and Assistant Administrator completed November 18, 2025 at approximately 1:30 PM confirmed the above findings.
Plan of Correction:An approved Plan of Correction is not on file.
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 clinical records (CR), job descriptions and interview with the agency Administrator and Assistant Administrator the agency failed to ensure staff made revisions to the plan of care based on patients conditions and needs for one (1) of three (3) records reviewed. CR #1.-
Findings include:
CR review completed November 18, 2025 between approximately 10:00 AM and 1:00 PM revealed the following:
CR #1, Start of Care (SOC): 10/2/2019; certification period: 10/30/2025-12-28-2025. No documentation on plan of care patient had bilateral nephrostomy tubes placed. No documentation a revised plan of care was sent to primary care physician; No documentation of a revision to the plan of care completed by the RN when the patient returned from a hospitalization.
Review of RN Clinical Manager Job Description November 24, 2025 at approximately 2:00 PM revealed: "Plan of treatment/care is reviewed by the attending physician and the agency's Clinical RN case manager or designee at the following times: as often as severity of the patient's condition requires" and "Revise patient's plan of care; communicate with interdisciplinary team involved in plan of care; communicate with the patient's primary care physician."
Interview with agency Administrator and Assistant Administrator November 18, 2025 at approximately 1:30 PM confirmed the above findings.
Plan of Correction:An approved Plan of Correction is not on file.
601.32(c) REQUIREMENT
DUTIES OF THE QUALIFIED LPN
Name - Component - 00
601.32(c) Duties of the Qualified
Licensed Practical Nurse. The
qualified licensed practical nurse:
(i) provides services in accordance
with agency policies,
(ii) prepares clinical and progress
notes,
(iii) assists the physician and/or
registered nurse in performing
specialized procedures,
(iv) prepares equipment and
materials for treatments observing
aseptic technique as required, and
(v) assists the patient in
learning appropriate self-care
techniques.
Observations:
Based on reviews of clinical records (CR), Job Description, and interview with agency Administrator and Assistant Administrator the License Practical Nurse (LPN) failed to complete a head to toe assessment (1) of three (3) records reviewed. CR #1.
Findings include:
CR review completed November 18, 2025 between approximately 10:00 AM and 1:00 PM revealed the following:
CR #1, Start of Care (SOC), 10/2/2019; certification period 10/30/2025-12/28/2025; Inaccurate/false documentation in MR, no vitals signs taken, no documentation to show nurse completed an assessment of the patient.
Review of LPN job description completed November 24, 2025 at approximately 2:00 PM revealed, "vital signs are required on every billable visit or documentation why they were not taken; complies with Home Health documentation/communication expectations."
Interview with agency Administrator and Assistant Administrator on November 18, 2025 at approximately 1:30 PM confirmed the above findings.
Plan of Correction:An approved Plan of Correction is not on file.
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