Initial Comments:
Based on the results of a revisit survey conducted on 9/29/2017 to determine compliance for the deficiencies cited at the 8/16/17 Medicare recertification and state relicensure survey, A Samuel's Christian Home Care failed to correct deficiencies cited under, and/or the state surveyor was unable to determine compliance with, the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.
Cross reference tags: G116, G134, G156, G159, G160, G164, G166, G168, G170, G173, G174, G176, G186, G236, G337.
Two (2) condition level deficiencies and thirteen (13) standard level deficiencies were recited as a result of the survey but Immediate Jeopardy was not identified.
Plan of Correction:
484.10(f) STANDARD
HOME HEALTH HOTLINE
Name - Component - 00
The patient has the right to be advised of the availability of the toll-free HHA hotline in the State.
When the agency accepts the patient for treatment or care, the HHA must advise the patient in writing of the telephone number of the home health hotline established by the State, the hours of its operation, and that the purpose of the hotline is to receive complaints or questions about local HHAs. The patient also has the right to use this hotline to lodge complaints concerning the implementation of the advanced directives requirements.
Observations:
Based on a review of the agency's written plan of correction and agency admission packet and staff (EMP) interview, the agency failed to fully implement the plan of correction to show patients would be advised in writing of the correct telephone number of the home health hotline established by the state.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag 0116 Home Health Hotline. Action: 1) had a meeting with the staff, Governing body and the 'Group of professional Personnel'. Action: The deficiency was looked at and discussed. We did not have active patients at the time of survey. The new patients will have the insert with the correct Hotline numbers for their complaints to file. The Administrator will daft a notice/ memo indication the updated number/s for the Home Health hotline. This document will be then approved by the Board of Governors'. The approved Hotline numbers will then be put on the notice board. A copy of which will be put in the Agency's Manual and also in the orientation manual. The originals of the patient handouts from which copies are made to be handed to the patient on admission will have the updated hotline numbers. Completion date: 09/09/2017. Monitored by: Administrator." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of the agency admission packet on 9/29/17 at approximately 11:15 a.m. revealed the governing body reviewed and approved on 9/1/17 a revision to the packet that replaced the incorrect hotline number with the correct hotline number.
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full compliance of the plan of correction, referring specifically to being able to show the process of notifying and educating patients on the updated hotline number, EMP1 stated "Those are the difficulties we are working with [no active patients], but we are not sitting."
Repeat deficiency 8/16/17
Plan of Correction:An approved Plan of Correction is not on file.
484.14(c) STANDARD
ADMINISTRATOR
Name - Component - 00
The administrator, who may also be the supervising physician or registered nurse required under paragraph (d) of this section, employs qualified personnel and ensures adequate staff education and evaluations.
Observations:
Based on a review of the agency's written plan of correction, agency policy and procedure, agency staff meeting documentation, agency governing body meeting minutes, governing body meeting minutes for a separate licensed/certified agency under the same ownership, and staff (EMP) interview, the administrator failed to fully implement the plan of correction to include ensuring personnel did not hold administrative and/or supervisory positions for another separately licensed/certified home health agency. Additionally, the administrator failed to show the agency was able to fully implement the plan of corrections as written; specifically, the process of ensuring nurses assigned to patients with specialized nursing needs had the educational and/or training qualifications to meet the needs of these patients.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag0134. Action: A combined meeting was held on 08/30/17. Attendance sheet signed and dated and kept on file. At this meeting the Medicare interpretive Guideline for Home Care agencies was consulted for discussion and understanding. The relevant section of 42 CFR 484.14 G123, G124 and the relevant example explaining how an Administrative authority and Supervisory function are (against the (Medicare regulation) delegated and takes place and therefore is not acceptable. Action: The Administrator will formulate a policy concerning 'ORGANIZATION, SERVICES AND ADMINISTRATION'. The policy would specifically state that the Administrative and Nurse Supervisory functions are not to be delegated against the Medicare guidelines and no inappropriate sharing of personnel shall take place against the Medicare guidelines. Further That the 'Group pf Professional and the Governing Board are separate for both agencies in accordance with the Medicare guidelines. Also the Administrative control lines of authority for the delegation of responsibility down to the patient care level are clearly set forth in writing and are readily identifiable. That it would be the duty of the Governing body and the Administrator/owner to enforce and follow the policy. The policy when approved by the Governing Board will be kept in the Agency's Manual for the record. The Board of Governors however will appoint a separate Administrator, Administrator Alternate and Nurse supervisor and her Alternate. Also the Board will see that no sharing/delegation of Administrative authority and Supervisory function to another person against the Medicare rules will take place. The Governing Board will monitor itself that another Administrator, Alternate Administrator, and Nurse Supervisor and her Alternate be appointed and approved in the meantime for this agency. All appointments of any staff for employment or any Administrative position will be approved by the Board of Governors' for compliance. The new Administrative positons thus approved will be put on the notice board. The names of the new appointees with their license and resume will be sent to the licensing Board. Reviewed the "behavioral element assessment items on the OASIS which every Registered Nurse/Psychiatric Nurse has to evaluate and answer which is no less nor more for the two professionals. Both have to assess the Neuro/Emotional/Behavior status items M1700, 1710, 1720, 1730, 1740, 1740, 1745 including mental status, psychosocial status, plus more. Reviewed the Professional files of all nurses on staff especially those with a BSN to see if they are capable of assessing by education/ training or experience. We will be diligent in monitoring, which will be monitored by the Administrator. Monitored by: The Governing Body and the Administrator to see the new policy is formulated and approved. Completion Date: 09/09/2017. Addendum: the agency will see that all service providers of all new special needs patients are adequately educated/trained and experienced to meet their patient's needs as according to Medicare guidelines. This will be done by: Looking at their professional files for the above requirements. If the service provider/s is/are not adequately trained the agency will not accept the patient for services. Monitored by: Administrator. Completion date: 09/09/17." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of agency policy and procedure on 9/29/17 at approximately 10:25 a.m. revealed "ORGANIZATION, SERVICES AND ADMINISTRATION ... The New Policy. Date Sept. 7th, 2017 ... The Administrative and Nurse Supervisory functions are not to be delegated against the Medicare guidelines and no in appropriate sharing of personnel shall take place against the Medicare guidelines. This would hold true for the Alternates for both the Administrator and the Nurse Supervisor. Further that the '[sic] Group pf [sic] Professional and the Governing Board are separate for both agencies in accordance with the Medicare guidelines. Also the Administrative control lines of authority for the delegation of responsibility down to the patient care level are clearly set forth in writing and are readily identifiable. That it would be the duty of the Governing body and the Administrator/owner to enforce and follow the policy. ... Approved By: [signed by EMP1 on 9/17/17]..."
A review of agency governing body meeting minutes on 9/29/17 at approximately 10:10 a.m. and revealed "Memorandum. The of [sic] Board of Governors has approved the following positions for [agency name] ... Administrator: [listed EMP1] Administrator Alternate: [listed EMP3] Nurse Supervisor: [listed EMP3] Nurse Supervisor Alternate [listed EMP2] ... Board of Governors' [sic] [listed EMP1] ... Approved by: [signed by EMP1 on 8/30/17] ... ."
A review of governing body meeting minutes for separately licensed/certified agency under the same ownership on 9/29/17 at approximately 10:15 a.m. revealed "Memorandum. The Board of Governors' [sic] has approved the following positions for [agency name of second agency] effective August 30th 2017. ... Administrator: [listed EMP3] Administrator Alternate: [listed EMP1] (Temporary) Nurse Supervisor: [listed EMP3] (Temporary) Nurse Supervisor Alternate: Vacant ... Board of Governors' [sic] [listed EMP3 and EMP13] ... Approved by: [signed by EMP3 on 8/30/17] ... ."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full compliance of the plan of correction, to include showing the process of evaluating referrals to ensure the assigned nursing staff had received the proper education and/or training to meet the needs of the patients, EMP1 stated "Those are the difficulties we are working with [no active patients], but we are not sitting."
An interview with EMP1 on 9/29/17 at approximately 10:36 a.m. confirmed the above findings and that the same staff members [EMP1, EMP2 and EMP3] have been appointed to administrative and supervisory roles for both agencies owned by EMP1. Additionally, when asked to show documentation that the licensing authority was notified of the administrative and supervisory changes on or prior to 9/16/17 (completion date per aforementioned plan of correction), EMP1 stated "I am notifying right now." When EMP1 was reminded that the completion date for this plan was 9/16/17, EMP1 stated "we are working on it and are waiting for the clarification from Medicare."
Repeat deficiency 8/16/17, 2/12/14
Plan of Correction:An approved Plan of Correction is not on file.
484.18 CONDITION
ACCEPTANCE OF PATIENTS, POC, MED SUPER
Name - Component - 00
Observations:
Based on a review of the agency's plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation and staff interview, the agency failed to fully implement the plan of correction to show agency compliance with requirement and that specific monitoring was in place to ensure that the plans of care included specific detailed orders covering all diagnosis, treatment interventions, monitoring, education, reporting parameters and measurable goals to ensure a timely discharge (G159), to fully implement the plan of correction to show agency compliance with requirement to ensure that the physician was consulted to approve additions or modifications to the plan of care (G160), to fully implement the plan of correction to show agency compliance with requirement to ensure notifying the physician of a change in the patient's condition that would suggest a need to alter the plan of care (G164), and to fully implement the plan of correction to show agency compliance with requirement ensuring verbal orders for changes in medications, wound care, and/or services provided were placed in writing and countersigned by the physician ordering the plan of care (G166).
The cumulative effect of these systemic practices resulted in the agency's inability to ensure the safety of the patients and the patient's needs were met but did not result in Immediate Jeopardy.
Findings Included:
Cross reference tags G159, G160, G164, G166.
Repeat deficiency 8/16/17, 2/12/14
Plan of Correction:An approved Plan of Correction is not on file.
484.18(a) STANDARD
PLAN OF CARE
Name - Component - 00
The plan of care developed in consultation with the agency staff covers all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items.
Observations:
Based on a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to show agency compliance with requirement and that specific monitoring was in place to ensure that the plans of care included specific detailed orders covering all diagnosis, treatment interventions, monitoring, education, reporting parameters and measurable goals to ensure a timely discharge.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag 0159. A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant policies/procedures (already in place) were reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey. Relevant charts were reviewed for this tag to look at the findings of the survey. Educated the service staff by reviewing the POC and treatment plans. Reviewed VO policy. Reviewed Wound care policy. Reviewed guidelines regarding "Change in medical condition of the patient policy'. Drug regimen review. Educated by doing a walk through the POC (485). Reviewed agency's policy on Conformance with physician orders for compliance. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of discharge. E) Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Governing Board. Completion Date: 09/09/2017." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (ensuring detailed orders covering all diagnosis include treatment interventions, monitoring, education and reporting parameters as well as including measurable goals to ensure a timely discharge).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete." When asked why the agency was not specifically monitoring for detailed orders that cover all diagnosis with treatment interventions, monitoring and education as well as measurable goals to ensure a timely discharge, EMP1 stated "If the physician wants that, they should ask for it" and "I think it would be the responsibility of the physician to call and ask for those goals if he wants to know that information."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to ensuring the plan of care included detailed orders that cover all diagnosis with treatment interventions, monitoring and education as well as measurable goals to ensure a timely discharge, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17, 2/12/14
Plan of Correction:An approved Plan of Correction is not on file.
484.18(a) STANDARD
PLAN OF CARE
Name - Component - 00
If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modification to the original plan.
Observations:
Based on a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to show agency compliance with requirement to ensure that the physician was consulted to approve additions or modifications to the plan of care.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag 0160. A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant policies/procedures (already in place) were reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey. The 'Guideline for Home Care' was reviewed which talks about the time allowed to see patient at the start of care/evaluations and to seek new orders from the physician if the patient is not seen in the required time frame. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of discharge. E) Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Governing Board. Completion Date: 09/09/2017. Addendum: The new therapy staff during their orientation will be given the Medicare rules and regulations for therapy services, also orientation of Agency's own policies and procedures, and the agencies own guidelines for home care. Each new therapist will sign and date the orientation thus given and that will be kept on file. Each therapy visit is going to be monitored every week for a month and then every other week for a month. Monitored by: Administrator. Completion Date 09/09/2017." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (ensuring that the physician was consulted to approve additions or modifications to the plan of care).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to consulting the physician to approve additions or modifications to the plan of care, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17
Plan of Correction:An approved Plan of Correction is not on file.
484.18(b) STANDARD
PERIODIC REVIEW OF PLAN OF CARE
Name - Component - 00
Agency professional staff promptly alert the physician to any changes that suggest a need to alter the plan of care.
Observations:
Based on a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to show agency compliance with requirement to ensure notifying the physician of a change in the patient's condition that would suggest a need to alter the plan of care.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag 0164. A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant policies/procedures (already in place) were reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey Educated the service staff by reviewing the POC and treatment plans. Reviewed VO policy. Reviewed Wound care policy. Reviewed guidelines regarding "Change in medical condition of the patient policy'. Reviewed agency's policy on Conformance with physician orders for compliance. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of discharge. Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Governing Board. Completion Date: 09/09/2017." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (notifying the physician of a change in the patient's condition that would suggest a need to alter the plan of care).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to notifying the physician of a change in the patient's condition that would suggest a need to alter the plan of care, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17
Plan of Correction:An approved Plan of Correction is not on file.
484.18(c) STANDARD
CONFORMANCE WITH PHYSICIAN ORDERS
Name - Component - 00
Verbal orders are put in writing and signed and dated with the date of receipt by the registered nurse or qualified therapist (as defined in section 484.4 of this chapter) responsible for furnishing or supervising the ordered services.
Observations:
Based on a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to show agency compliance with requirement ensuring verbal orders for changes in medications, wound care, and/or services provided were placed in writing and countersigned by the physician ordering the plan of care.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant policies/procedures (already in place) were reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey. Reviewed agency's policy on Conformance with physician orders for compliance. Reviewed agency's Drug regimen statement/policy Reviewed OASIS (assessment) items dealing with behavioral status required to be completed by all Registered Nurses. Reviewed Professional files of nurses with a BSN. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of
discharge. Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Governing Board. Completion Date: 09/09/2017." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (ensuring verbal orders for changes in medications, wound care, and/or services provided were placed in writing and countersigned by the physician ordering the plan of care).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to ensuring verbal orders for changes in medications, wound care, and/or services provided were placed in writing and countersigned by the physician ordering the plan of care, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17, 2/12/14
Plan of Correction:An approved Plan of Correction is not on file.
484.30 CONDITION
SKILLED NURSING SERVICES
Name - Component - 00
Observations:
Based on a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff interview, the agency failed to fully implement the plan of correction to show agency compliance with requirement to provide nursing services in accordance with the plan of care (G170), to fully implement the plan of correction to show agency compliance with requirement to ensure the registered nurse updated the plan of care with medication changes (G173), to fully implement the plan of correction to show agency compliance with requirement to ensure the registered nurse obtained appropriate physicians orders to provide appropriate skilled nursing services to patients (G174), and to fully implement the plan of correction to show agency compliance with requirement to ensure the registered nurse informed the physician of significant changes in the patient's condition (G176)
The cumulative effect of these systemic practices resulted in the agency's inability to ensure the safety of the patients and the patient's needs were met but did not result in Immediate Jeopardy.
Findings Included:
Cross reference tags G170, G173, G174, G176.
Repeat deficiency 8/16/17
Plan of Correction:An approved Plan of Correction is not on file.
484.30 STANDARD
SKILLED NURSING SERVICES
Name - Component - 00
The HHA furnishes skilled nursing services in accordance with the plan of care.
Observations:
Based on a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to show agency compliance with requirement to provide nursing services in accordance with the plan of care.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag 0170. A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant policies/procedures (already in place) were reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey. Reviewed: The 'Plan of Care Policy including the 485 and did a walk through the 485. Reviewed the document on 'Drug Regimen review' policy. Reviewed the personnel files of the nurses. Reviewed the VO policy. Reviewed the conformance with physician orders. Reviewed the policy regarding change in patient's condition. Reviewed Medicare discharge guidelines, Oasis submission guidelines. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of discharge. Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for a month and then upon discharge as a closed chart review. The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Governing Board. Completion Date: 09/09/2017." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (ensuring the agency provided nursing services in accordance with the plan of care).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to ensuring the agency provided nursing services in accordance with the plan of care, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17
Plan of Correction:An approved Plan of Correction is not on file.
484.30(a) STANDARD
DUTIES OF THE REGISTERED NURSE
Name - Component - 00
The registered nurse initiates the plan of care and necessary revisions.
Observations:
Based on a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to show agency compliance with requirement to ensure the registered nurse updated the plan of care with medication changes.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag 0173. A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant policies/procedures (already in place) were reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey. Educated the service staff by reviewing the POC and treatment plans. Reviewed VO policy. Reviewed Wound care policy. Reviewed guidelines regarding "Change in medical condition of the patient policy'. Educated by doing a walk through the POC (485). Reviewed agency's policy on Conformance with physician orders for compliance. Reviewed Drug Regimen Policy. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of discharge. E) Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for a month and then upon discharge as a closed chart review The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Governing Board. Completion Date: 09/09/2017." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (ensuring the registered nurse updated the plan of care with medication changes).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to ensuring the registered nurse updated the plan of care with medication changes, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17
Plan of Correction:An approved Plan of Correction is not on file.
484.30(a) STANDARD
DUTIES OF THE REGISTERED NURSE
Name - Component - 00
The registered nurse furnishes those services requiring substantial and specialized nursing skill.
Observations:
Based on a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to show agency compliance with requirement to ensure the registered nurse obtained appropriate physicians orders to provide appropriate skilled nursing services to patients.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag 0174. A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant policies/procedures (already in place) were reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey. Educated the service staff by reviewing the POC and treatment plans. Reviewed VO policy. Reviewed Wound care policy. Reviewed guidelines regarding "Change in medical condition of the patient policy. Reviewed agency's policy on Conformance with physician orders for compliance. Reviewed the "behavioral element assessment items on the OASIS which every registered Nurse has to evaluate and answer. Review the Professional files of all nurses on staff especially those with a BSN. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of discharge. E) Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Governing Board. Completion Date: 09/09/2017. Addendum: the agency will see that all service providers of all new special needs patients are adequately educated/trained and experienced to meet their patient's needs as according to Medicare guidelines. This will be done by: Looking at their professional files for the above requirements. If the service provider/s is/are not adequately trained the agency will not accept the patient for services. Monitored by: Administrator. Completion date: 09/09/17." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (ensuring that the registered nurse obtained appropriate physicians orders to provide appropriate skilled nursing services to patients).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to ensuring that the registered nurse obtained appropriate physicians orders to provide appropriate skilled nursing services to patients, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17
Plan of Correction:An approved Plan of Correction is not on file.
484.30(a) STANDARD
DUTIES OF THE REGISTERED NURSE
Name - Component - 00
The registered nurse prepares clinical and progress notes, coordinates services, informs the physician and other personnel of changes in the patient's condition and needs.
Observations:
Based on a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to show agency compliance with requirement to ensure the registered nurse informed the physician of significant changes in the patient's condition.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag 0176. A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant policies/procedures (already in place) were reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey Educated the service staff by reviewing the POC and treatment plans. Reviewed VO policy. Reviewed Wound care policy. Reviewed guidelines regarding "Change in medical condition of the patient' policy Reviewed 'Drug Regimen policy. Reviewed agency's policy on Conformance with physician orders for compliance. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of discharge. E) Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Governing Board. Completion Date: 09/09/2017." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (ensuring the registered nurse informed the physician of significant changes in the patient's condition).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to ensuring the registered nurse informed the physician of significant changes in the patient's condition, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17
Plan of Correction:An approved Plan of Correction is not on file.
484.32 STANDARD
THERAPY SERVICES
Name - Component - 00
The qualified therapist assists the physician in evaluating the patient's level of function, and helps develop the plan of care (revising it as necessary.)
Observations:
Based on a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to ensure physical therapy staff appropriately re-evaluated the patient's level of function in order to revise the plan of care as necessary.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag 0186. A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant policies/procedures (already in place) were reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey Educated the service staff by reviewing the POC and treatment plans. Reviewed 'Home Care Guidelines pertaining to discharge'. Reviewed VO policy. Reviewed agency's policy on conformance with physician orders for compliance. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of discharge. E) Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Governing Board. Completion Date: 09/09/2017. Addendum: The new therapy staff during their orientation will be given the Medicare rules and regulations for therapy services, also orientation of Agency's own policies and procedures, and the agencies own guidelines for home care. Each new therapist will sign and date the orientation thus given and that will be kept on file. Each therapy visit is going to be monitored every week for a month and then every other week for a month. Monitored by: Administrator. Completion Date 09/09/2017." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (ensuring physical therapy staff appropriately re-evaluated the patient's level of function in order to revise the plan of care as necessary).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). Additionally, EMP1 revealed that there was no therapy staff hired or under contract. When asked why the agency does not have any therapy staff, EMP1 stated "With no patients coming in, its difficult to find staff and even agree to an interview." When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to ensuring physical therapy staff appropriately re-evaluated the patient's level of function in order to revise the plan of care as necessary, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17
Plan of Correction:An approved Plan of Correction is not on file.
484.48 STANDARD
CLINICAL RECORDS
Name - Component - 00
A clinical record containing pertinent past and current findings in accordance with accepted professional standards is maintained for every patient receiving home health services. In addition to the plan of care, the record contains appropriate identifying information; name of physician; drug, dietary, treatment, and activity orders; signed and dated clinical and progress notes; copies of summary reports sent to the attending physician; and a discharge summary.
Observations:
Per the Pennsylvania Nurse Practice Act, "... RESPONSIBILITIES OF THE REGISTERED NURSE...21.11. General functions. (a) The registered nurse assesses human responses and plan, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of the following functions: (1) collects complete and ongoing data to determine nursing care needs...21.18. Standards of nursing conduct. (1) a registered nurse shall:...(5) Document and maintain accurate records. (b) A registered nurse may not:...(8) Falsify or knowingly make incorrect entries into the patient's record or other related documents..."
Based on a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to ensure the agency maintained accurate, complete clinical records in accordance with agency policy and the Pennsylvania Nurse Practice Act.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag 0236. A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant policies/procedures (already in place) were reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey. Reviewed duties of a registered nurse. Reviewed job description of the registered nurse. Reviewed the Retention and maintenance of Clinical records. Reviewed the 'Missed Visit' note sheet. Educated the service staff by reviewing the POC and treatment plans. Reviewed VO policy. Reviewed Wound care policy. Reviewed guidelines regarding "Change in medical condition of the patient policy'. Reinforced to set short and long term goals. Educated by doing a walk through the POC (485). Educated and by going over the Medicare guidelines regarding measurable goals and setting short term goals and longtime goals to achieve a timely discharge of the patient. Reviewed agency's policy on Conformance with physician orders for compliance. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of discharge. E) Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Administrator and Governing Board. Completion Date: 09/09/2017. Addendum: The policies reviewed were the discharge policies, VO policy, Retention of Clinical records, Maintenance of clinical records. Completion date: 09/09/2017. Monitored by: Administrator." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (ensuring the agency maintained accurate, complete clinical records in accordance with agency policy and the Pennsylvania Nurse Practice Act).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to ensuring the agency maintained accurate, complete clinical records in accordance with agency policy and the Pennsylvania Nurse Practice Act, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17, 2/12/14
Plan of Correction:An approved Plan of Correction is not on file.
484.55(c) STANDARD
DRUG REGIMEN REVIEW
Name - Component - 00
The comprehensive assessment must include 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's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to ensure the agency maintained a complete ongoing medication profile for each patient in order to identify potential adverse effects, drug reactions, ineffective drug therapy, significant side effects, drug interactions, duplicative therapies and/or noncompliance.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag 0337. A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant policies/procedures (already in place) were reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey. The 'Drug regimen 'was reviewed. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of discharge. E) Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Governing Board. Completion Date: 09/09/2017. Addendum: The Policies reviewed 08/30/2017 were, Drug regime review policy, VO policy and conformance with physician orders. Completion date: 09/09/2017. Monitored by: Administrator." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (ensuring the the agency maintained a complete ongoing medication profile for each patient in order to identify potential adverse effects, drug reactions, ineffective drug therapy, significant side effects, drug interactions, duplicative therapies and/or noncompliance).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to ensuring the the agency maintained a complete ongoing medication profile for each patient in order to identify potential adverse effects, drug reactions, ineffective drug therapy, significant side effects, drug interactions, duplicative therapies and/or noncompliance, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17, 2/12/14
Plan of Correction:An approved Plan of Correction is not on file.
Initial Comments:
Based on the results of a revisit survey conducted on 9/29/2017 to determine compliance for the deficiencies cited at the 8/16/17 Medicare recertification and state relicensure survey, A Samuel's Christian Home Care failed to correct deficiencies cited under, and/or the state surveyor was unable to determine compliance with, the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.
Cross reference tags: M1001, M1004, M1005, M1006, M1016, M1018, M1019, M1020, M1021, M1022, M0123, M1026, M1035.
Plan of Correction:
601.21 REQUIREMENT
ORGANIZATION, SERVICES, ADMINISTRATION
Name - Component - 00
601.21 II. ORGANIZATION, SERVICES,
ADMINISTRATION.
Observations:
Based on a review of the agency's written plan of correction, agency policy and procedure, agency staff meeting documentation, governing body meeting minutes, governing body meeting minutes for a separate licensed/certified agency under the same ownership, and staff interview, the governing body failed to implement the plan of correction to ensure it did not appoint an administrator with administrative or supervisory functions at another licensed and certified home health agency (M1004). The administrator failed to implement the plan of correction to include organizing/directing the agency's ongoing functions and ensuring administrator, alternate administrator, supervising registered nurse, governing body, and group of professional personnel were not shared with a separately licensed/certified home health agency; to show the agency was able to fully implement the plan of corrections as written; specifically, the process of ensuring nurses assigned to patients with specialized nursing needs had the educational and/or training qualifications to meet the needs of these patients; and to fully implement the plan of correction to include ensuring the supervising registered nurse was available at all times during operating hours to participate in activities relevant to professional services provided. The supervising nurse and alternate held administrative/supervisory positions with a separate licensed/certified home health agency (M1005 and M1006).
Findings Included:
Cross reference tags M1004, 1005, 1006.
Repeat deficiency 8/16/17
Plan of Correction:An approved Plan of Correction is not on file.
601.21(c) REQUIREMENT
GOVERNING BODY
Name - Component - 00
601.21(c) Governing Body. A governing
body (or designated persons so
functioning) assumes full legal
authority and responsibility for the
operation of the agency. The
governing body appoints: (i) a
qualified administrator, (ii) arranges
for professional service, (iii) adopts
and periodically reviews written
bylaws or an acceptable equivalent,
and (iv) oversees the management and
fiscal affairs of the agency. The
name and address of each officer,
director, and owner are disclosed to
the State agency with changes reported
promptly.
Observations:
Based on a review of the agency's written plan of correction, agency policy and procedure, agency staff meeting documentation, governing body meeting minutes, and governing body meeting minutes for separately licensed/certified agency under the same ownership, and staff (EMP) interview, the governing body failed to implement the plan of correction to ensure it did not appoint an administrator with administrative or supervisory functions at another licensed and certified home health agency.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag 1004. Action: A combined meeting was held on 08/30/17. Attendance sheet signed and dated and kept on file. At this meeting the Medicare interpretive Guideline for Home Care agencies was consulted for discussion and understanding. The relevant section of 42 CFR 484.14 G123, G124 and the relevant example explaining how an Administrative authority and Supervisory function are (against the (Medicare regulation) delegated and takes place and therefore is not acceptable. Action: The Administrator will formulate a policy concerning 'ORGANIZATION, SERVICES AND ADMINISTRATION'. The policy would specifically state that the Administrative and Nurse Supervisory Medicare guidelines and no inappropriate sharing of personnel shall take place against the Medicare guidelines. Further That the 'Group pf Professional and the Governing Board are separate for both agencies in accordance with the Medicare guidelines. Also the Administrative control lines of authority for the delegation of responsibility down to the patient care level are clearly set forth in writing and are readily identifiable. That it would be the duty of the Governing body and the Administrator/owner to enforce and follow the policy. The policy when approved by the Governing Board will be kept in the Agency's Manual for the record. The Board of Governors however will appoint a separate Administrator, Administrator Alternate and Nurse supervisor and her Alternate. Also the Board will see that no sharing/delegation of Administrative authority and Supervisory function to another person against the Medicare rules will take place. The Governing Board will monitor itself that another Administrator, Alternate Administrator, and Nurse Supervisor and her Alternate be appointed and approved in the meantime for this agency. All appointments of any staff for employment or any Administrative position will be approved by the Board of Governors' for compliance. The new Administrative positons thus approvedwill be put on the notice board. The names of the new appointees with their license and resume will be sent to the licensing Board. Monitored by: The Governing Body and the Administrator to see the new policy is formulated and approved. Completion Date: 09/09/2017. Addendum:The re-education of all Governing Board members to policies in this citation was done and completed on 08/30/2017. Completion Date: 08/30/2017." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of agency policy and procedure on 9/29/17 at approximately 10:25 a.m. revealed "ORGANIZATION, SERVICES AND ADMINISTRATION ... The New Policy. Date Sept. 7th, 2017 ... The Administrative and Nurse Supervisory functions are not to be delegated against the Medicare guidelines and no in appropriate sharing of personnel shall take place against the Medicare guidelines. This would hold true for the Alternates for both the Administrator and the Nurse Supervisor. Further that the '[sic] Group pf [sic] Professional and the Governing Board are separate for both agencies in accordance with the Medicare guidelines. Also the Administrative control lines of authority for the delegation of responsibility down to the patient care level are clearly set forth in writing and are readily identifiable. That it would be the duty of the Governing body and the Administrator/owner to enforce and follow the policy. ... Approved By: [signed by EMP1 on 9/17/17]..."
A review of agency governing body meeting minutes on 9/29/17 at approximately 10:10 a.m. and revealed "Memorandum. The of [sic] Board of Governors has approved the following positions for [agency name] ... Administrator: [listed EMP1] Administrator Alternate: [listed EMP3] Nurse Supervisor: [listed EMP3] Nurse Supervisor Alternate [listed EMP2] ... Board of Governors' [sic] [listed EMP1] ... Approved by: [signed by EMP1 on 8/30/17] ... ."
A review of governing body meeting minutes for separately licensed/certified agency under the same ownership on 9/29/17 at approximately 10:15 a.m. revealed "Memorandum. The Board of Governors' [sic] has approved the following positions for [agency name of second agency] effective August 30th 2017. ... Administrator: [listed EMP3] Administrator Alternate: [listed EMP1] (Temporary) Nurse Supervisor: [listed EMP3] (Temporary) Nurse Supervisor Alternate: Vacant ... Board of Governors' [sic] [listed EMP3 and EMP13] ... Approved by: [signed by EMP3 on 8/30/17] ... ."
An interview with EMP1 on 9/29/17 at approximately 10:36 a.m. confirmed the above findings and that the same staff members [EMP1, EMP2 and EMP3] have been appointed to administrative and supervisory roles for both agencies owned by EMP1. Additionally, when asked to show documentation that the licensing authority was notified of the administrative and supervisory changes on or prior to 9/16/17 (completion date per aforementioned plan of correction), EMP1 stated "I am notifying right now." When EMP1 was reminded that the completion date for this plan was 9/16/17, EMP1 stated "we are working on it and are waiting for the clarification from Medicare."
Repeat deficiency 8/16/17
Plan of Correction:An approved Plan of Correction is not on file.
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 the agency's written plan of correction, agency policy and procedure, agency staff meeting documentation, agency governing body meeting minutes, and governing body meeting minutes for separately licensed/certified agency under the same ownership, and staff (EMP) interview, the administrator failed to implement the plan of correction to include organizing/directing the agency's ongoing functions and ensuring administrator, alternate administrator, supervising registered nurse, governing body, and group of professional personnel were not shared with a separately licensed/certified home health agency. Additionally, the administrator failed to show the agency was able to fully implement the plan of corrections as written; specifically, the process of ensuring nurses assigned to patients with specialized nursing needs had the educational and/or training qualifications to meet the needs of these patients.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "A combined meeting was held on 08/30/17. Attendance sheet signed and dated and kept on file. At this meeting the Medicare interpretive Guideline for Home Care agencies was consulted for discussion and understanding. The relevant section of 42 CFR 484.14 G123, G124 and the relevant example explaining how an Administrative authority and Supervisory function are (against the (Medicare regulation)delegated and takes place and therefore is not acceptable. Action: The Administrator will formulate a policy concerning 'ORGANIZATION, SERVICES AND ADMINISTRATION'. The policy would specifically state that the Administrative and Nurse Supervisory functions are not to be delegated against the Medicare guidelines and no inappropriate sharing of personnel shall take place against the Medicare guidelines. Further That the 'Group pf Professional and the Governing Board are separate for both agencies in accordance with the Medicare guidelines. Also the Administrative control lines of authority for the delegation of responsibility down to the patient care level are clearly set forth in writing and are readily identifiable. That it would be the duty of the Governing body and the Administrator/owner to enforce and follow the policy. The policy when approved by the Governing Board will be kept in the Agency's Manual for the record. The Board of Governors however will appoint a separate Administrator, Administrator Alternate and Nurse supervisor and her Alternate. Also the Board will see that no sharing/delegation of Administrative authority and Supervisory function to another person against the Medicare rules will take place. The Governing Board will monitor itself that another Administrator, Alternate Administrator, and Nurse Supervisor and her Alternate be appointed and approved in the meantime for this agency. All appointments of any staff for employment or any Administrative position will be approved by the Board of Governors' for compliance. The new Administrative positons thus approved will be put on the notice board. The names of the new appointees with their license and resume will be sent to the licensing Board. Monitored by: The Governing Body and the Administrator to see the new policy is formulated and approved. Completion Date: 09/09/2017. Addendum: The re-education of all Governing Board members to policies in this citation was done and completed on 08/30/2017. Completion Date: 08/30/2017. Addendum: the agency will see that all service providers of all new special needs patients are adequately educated/trained and experienced to meet their patient's needs as according to Medicare guidelines. This will be done by: Looking at their professional files for the above requirements. If the service provider/s is/are not adequately trained the agency will not accept the patient for services. Monitored by: Administrator. Completion date: 09/09/17." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of agency policy and procedure on 9/29/17 at approximately 10:25 a.m. revealed "ORGANIZATION, SERVICES AND ADMINISTRATION ... The New Policy. Date Sept. 7th, 2017 ... The Administrative and Nurse Supervisory functions are not to be delegated against the Medicare guidelines and no in appropriate sharing of personnel shall take place against the Medicare guidelines. This would hold true for the Alternates for both the Administrator and the Nurse Supervisor. Further that the '[sic] Group pf [sic] Professional and the Governing Board are separate for both agencies in accordance with the Medicare guidelines. Also the Administrative control lines of authority for the delegation of responsibility down to the patient care level are clearly set forth in writing and are readily identifiable. That it would be the duty of the Governing body and the Administrator/owner to enforce and follow the policy. ... Approved By: [signed by EMP1 on 9/17/17]..."
A review of agency governing body meeting minutes on 9/29/17 at approximately 10:10 a.m. and revealed "Memorandum. The of [sic] Board of Governors has approved the following positions for [agency name] ... Administrator: [listed EMP1] Administrator Alternate: [listed EMP3] Nurse Supervisor: [listed EMP3] Nurse Supervisor Alternate [listed EMP2] ... Board of Governors' [sic] [listed EMP1] ... Approved by: [signed by EMP1 on 8/30/17] ... ."
A review of governing body meeting minutes for separately licensed/certified agency under the same ownership on 9/29/17 at approximately 10:15 a.m. revealed "Memorandum. The Board of Governors' [sic] has approved the following positions for [agency name of second agency] effective August 30th 2017. ... Administrator: [listed EMP3] Administrator Alternate: [listed EMP1] (Temporary) Nurse Supervisor: [listed EMP3] (Temporary) Nurse Supervisor Alternate: Vacant ... Board of Governors' [sic] [listed EMP3 and EMP13] ... Approved by: [signed by EMP3 on 8/30/17] ... ."
An interview with EMP1 on 9/29/17 at approximately 10:36 a.m. confirmed the above findings and that the same staff members [EMP1, EMP2 and EMP3] have been appointed to administrative and supervisory roles for both agencies owned by EMP1. Additionally, when asked to show documentation that the licensing authority was notified of the administrative and supervisory changes on or prior to 9/16/17 (completion date per aforementioned plan of correction), EMP1 stated "I am notifying right now." When EMP1 was reminded that the completion date for this plan was 9/16/17, EMP1 stated "we are working on it and are waiting for the clarification from Medicare."
Repeat deficiency 8/16/17, 2/12/14
Plan of Correction:An approved Plan of Correction is not on file.
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 a review of the agency's written plan of correction, agency policy and procedure, agency staff meeting documentation, agency governing body meeting minutes, governing body meeting minutes for separate licensed/certified agency under the same ownership, and staff (EMP) interview, the administrator failed to fully implement the plan of correction to include ensuring the supervising registered nurse was available at all times during operating hours to participate in activities relevant to professional services provided. The supervising nurse and alternate held administrative/supervisory positions with a separate licensed/certified home health agency.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "A combined meeting was held on 08/30/17. Attendance sheet signed and dated and kept on file. At this meeting the Medicare interpretive Guideline for Home Care agencies was consulted for discussion and understanding. The relevant section of 42 CFR 484.14 G123, G124 and the relevant example explaining supervisory function are (against the (Medicare regulation) delegated and takes place and therefore is not acceptable. Action: The Administrator will formulate a policy concerning 'ORGANIZATION, SERVICES AND ADMINISTRATION'. The policy would specifically state that the Administrative and Nurse Supervisory functions are not to be delegated against the Medicare guidelines and no inappropriate sharing of personnel shall take place against the Medicare guidelines. Further That the 'Group pf Professional and the Governing Board are separate for both agencies in accordance with the Medicare guidelines. Also the Administrative control lines of authority for the delegation of responsibility down to the patient care level are clearly set forth in writing and are readily identifiable. That it would be the duty of the Governing body and the Administrator/owner to enforce and follow the policy. The policy when approved by the Governing Board will be kept in the Agency's Manual for the record. The Board of Governors however will appoint a separate Administrator, Administrator Alternate and Nurse supervisor and her Alternate. Also the Board will see that no sharing/delegation of Administrative authority and Supervisory function to another person against the Medicare rules will take place. The Governing Board will monitor itself that another Administrator, Alternate Administrator, and Nurse Supervisor and her Alternate be appointed and approved in the meantime for this agency. All appointments of any staff for employment or any Administrative position will be approved by the Board of Governors' for compliance. The new Administrative positons thus approved will be put on the notice board. The names of the new appointees with their license and resume will be sent to the licensing Board. Monitored by: The Governing Body and the Administrator to see the new policy is formulated and approved. Completion Date: 09/09/2017. Addendum: The re-education of all Governing Board members to policies in this citation was done and completed on 08/30/2017. Completion Date: 08/30/2017." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of agency policy and procedure on 9/29/17 at approximately 10:25 a.m. revealed "ORGANIZATION, SERVICES AND ADMINISTRATION ... The New Policy. Date Sept. 7th, 2017 ... The Administrative and Nurse Supervisory functions are not to be delegated against the Medicare guidelines and no in appropriate sharing of personnel shall take place against the Medicare guidelines. This would hold true for the Alternates for both the Administrator and the Nurse Supervisor. Further that the '[sic] Group pf [sic] Professional and the Governing Board are separate for both agencies in accordance with the Medicare guidelines. Also the Administrative control lines of authority for the delegation of responsibility down to the patient care level are clearly set forth in writing and are readily identifiable. That it would be the duty of the Governing body and the Administrator/owner to enforce and follow the policy. ... Approved By: [signed by EMP1 on 9/17/17]..."
A review of agency governing body meeting minutes on 9/29/17 at approximately 10:10 a.m. and revealed "Memorandum. The of [sic] Board of Governors has approved the following positions for [agency name] ... Administrator: [listed EMP1] Administrator Alternate: [listed EMP3] Nurse Supervisor: [listed EMP3] Nurse Supervisor Alternate [listed EMP2] ... Board of Governors' [sic] [listed EMP1] ... Approved by: [signed by EMP1 on 8/30/17] ... ."
A review of governing body meeting minutes for separately licensed/certified agency under the same ownership on 9/29/17 at approximately 10:15 a.m. revealed "Memorandum. The Board of Governors' [sic] has approved the following positions for [agency name of second agency] effective August 30th 2017. ... Administrator: [listed EMP3] Administrator Alternate: [listed EMP1] (Temporary) Nurse Supervisor: [listed EMP3] (Temporary) Nurse Supervisor Alternate: Vacant ... Board of Governors' [sic] [listed EMP3 and EMP13] ... Approved by: [signed by EMP3 on 8/30/17] ... ."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full compliance of the plan of correction, to include showing the process of evaluating referrals to ensure the assigned nursing staff had received the proper education and/or training to meet the needs of the patients, EMP1 stated "Those are the difficulties we are working with [no active patients], but we are not sitting."
An interview with EMP1 on 9/29/17 at approximately 10:36 a.m. confirmed the above findings and that the same staff members [EMP1, EMP2 and EMP3] have been appointed to administrative and supervisory roles for both agencies owned by EMP1. Additionally, when asked to show documentation that the licensing authority was notified of the administrative and supervisory changes on or prior to 9/16/17 (completion date per aforementioned plan of correction), EMP1 stated "I am notifying right now." When EMP1 was reminded that the completion date for this plan was 9/16/17, EMP1 stated "we are working on it and are waiting for the clarification from Medicare."
Repeat deficiency 8/16/17, 2/12/14
Plan of Correction:An approved Plan of Correction is not on file.
601.31 REQUIREMENT
ACCEPTANCE OF PT, POT, MED SUPV
Name - Component - 00
601.31 IV ACCEPTANCE OF PATIENTS,
PLAN OF TREATMENT, MEDICAL
SUPERVISION.
Observations:
Based on a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff interview, the agency failed to fully implement the plan of correction to show agency compliance with requirement and that specific monitoring was in place to ensure that the plans of care included specific detailed orders covering all diagnosis, treatment interventions, monitoring, education, reporting parameters and measurable goals to ensure a timely discharge and to ensure that the physician was consulted to approve additions or modifications to the plan of care (M1018), failed to fully implement the plan of correction to show agency compliance with requirement to ensure notifying the physician of a change in the patient's condition that would suggest a need to alter the plan of care (M1019), and failed to fully implement the plan of correction to show agency compliance with requirement ensuring verbal orders for changes in medications, wound care, and/or services provided were placed in writing and countersigned by the physician ordering the plan of care (M1020).
Findings Included:
Cross reference tags M1018, 1019, 1020.
Repeat deficiency 8/16/17
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 a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to show agency compliance with requirement and that specific monitoring was in place to ensure that the plans of care included specific detailed orders covering all diagnosis, treatment interventions, monitoring, education, reporting parameters and measurable goals to ensure a timely discharge and to ensure that the physician was consulted to approve additions or modifications to the plan of care.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag 1018. A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey. Relevant charts were reviewed for this tag to look at the findings of the survey. Educated the service staff by reviewing the POC and treatment plans. Reviewed VO policy. Reviewed Wound care policy. Reviewed guidelines regarding "Change in medical condition of the patient policy'. Drug regimen review. Educated by doing a walk through the POC (485). Reviewed agency's policy on conformance with physician orders for compliance. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of discharge. E) Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Governing Board. Completion Date: 09/09/2017. Addendum: Discussed 'Plan of Care' (485) line 22 as it relates to goals for the patient. Discussed the last page of the 'OASIS' as it relates to goals and the dates set to achieve the goals for the patient. Also reviewed Medicare guidelines that "Plan of Care should be established based on evaluation of the patient's immediate and longtime needs". Further "Discipline goals and date on which they would be achieved with specific time frames, both short and long time frames to facilitate a timely discharge. Completion Date: 09/09/2017. Monitored By: Administrator." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (ensuring detailed orders covering all diagnosis include treatment interventions, monitoring, education and reporting parameters as well as including measurable goals to ensure a timely discharge and ensuring that the physician was consulted to approve additions or modifications to the plan of care).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete." When asked why the agency was not specifically monitoring for detailed orders that cover all diagnosis with treatment interventions, monitoring and education as well as measurable goals to ensure a timely discharge and ensuring the physician was consulted to approve additions and modifications to the plan of care, EMP1 stated "If the physician wants that, they should ask for it" and "I think it would be the responsibility of the physician to call and ask for those goals if he wants to know that information."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to ensuring the plan of care included detailed orders that cover all diagnosis with treatment interventions, monitoring and education as well as measurable goals to ensure a timely discharge and ensuring that the physician was consulted to approve additions or modifications to the plan of care, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17, 2/12/14
Plan of Correction:Tag 1018.
Since the State tags match the Federal tags, these State POC's are being submitted per federal tag rejection directives.
This POC is being resubmitted as per recent rejection reasons box directive i.e.
Other: The Department has updated your Federal 2567 and removed the Governoring Body Condition and related deficiencies. Please Resubmit Plan of Correction.
POC submitted 11/06/2017. This POC is in response to the third 'SOD' (2567) posted this morning for the same survey conducted on 09/29/2017.
The POC for this deficiency was submitted to the SA agency and was approved. We are committed to following that POC as it has kept us in substantial compliance. The new monitoring tools would be used to ensure that agency continues to strive towards perfection and in doing so to see that the plans of care included specific detailed orders covering all PERTINENT diagnosis, treatment interventions, monitoring, education, reporting parameters and goals to ensure a timely discharge and to ensure that the physician was consulted to approve additions or modifications to the plan of care and to show agency compliance with requirement to ensure notifying the physician of a change in the patient's condition that would suggest a need to alter the plan of care, and to show agency compliance with requirement ensuring verbal orders for changes in medications, wound care, and/or services provided were placed in writing and countersigned by the physician ordering the plan of care.
Refer to 42 CFR 484.14 G140 which states:" Available at all times during operating hours" means being readily available on the premises or by telecommunications. How the supervising physician or supervising registered nurse structures his or her availability is a management decision for the HHA.
Addendum:
This POC is for the resurvey done on 09/29/17. With the same tag deficiencies, we are resubmitting the POC.s for these tags already approved by the SA surveyor on 09/25/17. We are going to implement the same 'POC'for the new patients referrals we get.
Referral of patients to any home care agency is strictly based on patient's choice. We have no control of that. We ask friends/ neighbors and relatives to choose our agency, but it again is dependent upon patient's choice.
The overall 'POC' approved by the surveyors in September 2017 is being implemented.
A combined meeting held of staff, Board of Governors' members of the G.O P.P in August 2017
The Clinical Record deficiencies in the (SOD) pertaining to each Tag were studied along with the relevant policies/procedures (already in place) were reviewed.
Maintenance of 'Clinical records was studied to ensure that 'A clinical record containing pertinent past and current findings in accordance with accepted professional standards is maintained for every patient receiving home health services. In addition to the plan of care, the record contains appropriate identifying information; name of physician; drug, dietary, treatment, and activity orders; signed and dated clinical and progress notes; copies of summary reports sent to the attending physician; and a discharge summary'.
The Plan of Correction: Relevant charts were reviewed for deficiencies in each tag to look at the findings of the survey.
Educated the service staff by reviewing the POC and treatment plans.
Reviewed VO policy.
Reviewed Wound care policy.
Reviewed guidelines regarding "Change in medical condition of the patient policy'.
Drug regimen review.
Educated by doing a walk through the POC (485) and the 'Plan Of Treatment' and its periodic review.
Reviewed agency's policy on Conformance with physician orders for compliance.
Duties if the 'Registered Nurse'.
Therapy guidelines were looked at.
Discharge Policy.
Tools for monitoring to be used:
The 'Self Audit' sheet which each service provider will use for each patient.
Active Chart Review tool will be used while the patient is still on service.
Closed Chart Review will be used at time of discharge.
E) Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file.
Monitored by: Administrator.
Completion Date: 10/27/2017
Addendum: The staff was reeducated on 'Policies on 08/30/2017.
The chart reviewed during the survey were of patients that had been all discharged.
The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months.
Monitored by: Governing Board.
Completion Date: 10/27/2017
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 the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to show agency compliance with requirement to ensure notifying the physician of a change in the patient's condition that would suggest a need to alter the plan of care.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed " Tag 1019. Tag 0164. A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant policies/procedures (already in place) were reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey Educated the service staff by reviewing the POC and treatment plans. Reviewed VO policy. Reviewed Wound care policy. Reviewed agency's policy on Conformance with physician orders for compliance. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of discharge. Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Governing Board. Completion Date: 09/09/2017." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (notifying the physician of a change in the patient's condition that would suggest a need to alter the plan of care).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to notifying the physician of a change in the patient's condition that would suggest a need to alter the plan of care, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17
Plan of Correction:An approved Plan of Correction is not on file.
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's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to show agency compliance with requirement ensuring verbal orders for changes in medications, wound care, and/or services provided were placed in writing and countersigned by the physician ordering the plan of care.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag 1020. A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant policies/procedures (already in place) were reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey. Reviewed agency's policy on Conformance with physician orders for compliance. Reviewed agency's Drug regimen statement/policy Reviewed OASIS (assessment) items dealing with behavioral status required to be completed by all Registered Nurses. Reviewed Professional files of nurses with a BSN. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of discharge. Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Governing Board. Completion Date: 09/09/2017." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (ensuring verbal orders for changes in medications, wound care, and/or services provided were placed in writing and countersigned by the physician ordering the plan of care).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to ensuring verbal orders for changes in medications, wound care, and/or services provided were placed in writing and countersigned by the physician ordering the plan of care, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17, 2/12/14
Plan of Correction:An approved Plan of Correction is not on file.
601.32 REQUIREMENT
SKILLED NURSING SERVICE
Name - Component - 00
601.32 V. SKILLED NURSING SERVICE.
Observations:
Based on a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff interview, the agency failed to fully implement the plan of correction to show agency compliance with requirement to provide nursing services in accordance with the plan of care (M1022), to fully implement the plan of correction to show agency compliance with requirement to ensure the registered nurse updated the plan of care with medication changes, to fully implement the plan of correction to show agency compliance with requirement to ensure the registered nurse obtained appropriate physicians orders to provide appropriate skilled nursing services to patients, and to fully implement the plan of correction to show agency compliance with requirement to ensure the registered nurse informed the physician of significant changes in the patient's condition (M1023)
Findings Included:
Cross reference tags 1022, 1023.
Repeat deficiency 8/16/17
Plan of Correction:An approved Plan of Correction is not on file.
601.32(a) REQUIREMENT
SUPERVISION
Name - Component - 00
601.32(a) Supervision. The home
health agency provides skilled nursing
service by or under the supervision of
a registered nurse and in accordance
with the plan of treatment.
Observations:
Based on a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to show agency compliance with requirement to provide nursing services in accordance with the plan of care.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag Tag 1022. A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant policies/procedures (already in place) were reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey. Reviewed: The 'Plan of Care Policy including the 485 and did a walk through the 485. Reviewed the document on 'Drug Regimen review' policy. Reviewed the personnel files of the nurses. Reviewed the VO policy. Reviewed the conformance with physician orders. Reviewed the policy regarding change in patient's condition. Reviewed Medicare discharge guidelines, Oasis submission guidelines. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Governing Board. Completion Date: 09/09/2017." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (ensuring the agency provided nursing services in accordance with the plan of care).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to ensuring the agency provided nursing services in accordance with the plan of care, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17
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 a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to show agency compliance with requirement to ensure the registered nurse updated the plan of care with medication changes, to show agency compliance with requirement to ensure the registered nurse obtained appropriate physicians orders to provide appropriate skilled nursing services to patients, and to show agency compliance with requirement to ensure the registered nurse informed the physician of significant changes in the patient's condition.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag 1023. A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant policies/procedures (already in place) were reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey. Educated the service staff by reviewing the Reviewed VO policy. Reviewed Wound care policy. Reviewed guidelines regarding "Change in medical condition of the patient policy. Reviewed agency's policy on Conformance with physician orders for compliance. Reviewed the "behavioral element assessment items on the OASIS which every registered Nurse has to evaluate and answer. Review the Professional files of all nurses on staff especially those with a BSN. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of discharge. E) Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Governing Board. Completion Date: 09/09/2017. Addendum: the agency will see that all service providers of all new special needs patients are adequately educated/trained and experienced to meet their patient's needs as according to Medicare guidelines. This will be done by: Looking at their professional files for the above requirements. If the service provider/s is/are not adequately trained the agency will not accept the patient for services. Monitored by: Administrator. Completion date: 09/09/17." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (ensuring the registered nurse updated the plan of care with medication changes, that the registered nurse obtained appropriate physicians orders to provide appropriate skilled nursing services to patients, and that the registered nurse informed the physician of significant changes in the patient's condition).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to ensuring the registered nurse updated the plan of care with medication changes, obtained appropriate physicians orders to provide appropriate skilled nursing services to patients and informed the physician of significant changes in the patient's condition, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17
Plan of Correction:Tag 1023.
Since the State tags match the Federal tags, these State POC's are being submitted per federal tag rejection directives.
This POC is being resubmitted as per recent rejection reasons box directive i.e.
Other: The Department has updated your Federal 2567 and removed the Governoring Body Condition and related deficiencies. Please Resubmit Plan of Correction.
POC submitted 11/06/2017. This POC is in response to the third 'SOD' (2567) posted this morning for the same survey conducted on 09/29/2017.
The POC for this deficiency was submitted to the SA agency and was approved. We are committed to following that POC as it has kept us in substantial compliance. The new monitoring tools would be used to ensure that agency continues to strive towards perfection and in doing so to see that 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.
Addendum:
This POC is for the resurvey done on 09/29/17. With the same tag deficiencies, we are resubmitting the POC.s for these tags already approved by the SA surveyor on 09/25/17. We are going to implement the same 'POC'for the new patients referrals we get.
Referral of patients to any home care agency is strictly based on patient's choice. We have no control of that. We ask friends/ neighbors and relatives to choose our agency, but it again is dependent upon patient's choice.
The overall 'POC' approved by the surveyors in September 2017 is being implemented.
A combined meeting held of staff, Board of Governors' members of the G.O P.P in August 2017
The Clinical Record deficiencies in the (SOD) pertaining to each Tag were studied along with the relevant policies/procedures (already in place) were reviewed.
Maintenance of 'Clinical records was studied to ensure that 'A clinical record containing pertinent past and current findings in accordance with accepted professional standards is maintained for every patient receiving home health services. In addition to the plan of care, the record contains appropriate identifying information; name of physician; drug, dietary, treatment, and activity orders; signed and dated clinical and progress notes; copies of summary reports sent to the attending physician; and a discharge summary'.
The Plan of Correction: Relevant charts were reviewed for deficiencies in each tag to look at the findings of the survey.
Educated the service staff by reviewing the POC and treatment plans.
Reviewed VO policy.
Reviewed Wound care policy.
Reviewed guidelines regarding "Change in medical condition of the patient policy'.
Drug regimen review.
Educated by doing a walk through the POC (485) and the 'Plan Of Treatment' and its periodic review.
Reviewed agency's policy on Conformance with physician orders for compliance.
Duties if the 'Registered Nurse'.
Therapy guidelines were looked at.
Discharge Policy.
Tools for monitoring to be used:
The 'Self Audit' sheet which each service provider will use for each patient.
Active Chart Review tool will be used while the patient is still on service.
Closed Chart Review will be used at time of discharge.
E) Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file.
Monitored by: Administrator.
Completion Date: 10/27/2017
Addendum: The staff was reeducated on 'Policies on 08/30/2017.
The chart reviewed during the survey were of patients that had been all discharged.
The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months.
Monitored by: Governing Board.
Completion Date: 10/27/2017
601.33(a) REQUIREMENT
QUALIFIED THERAPISTS
Name - Component - 00
601.33(a) Qualified Therapists. Any
therapy services offered by the agency
directly or under arrangement are
given by or under the supervision of a
qualified therapist in accordance with
the plan of treatment. The qualified
therapist:
(i) assists the physician in
evaluating level of function,
(ii) helps develop the plan of
treatment (revising as necessary),
(iii) prepares clinical and progress
notes,
(iv) advises and consults with the
family and other agency personnel, and
(v) participates in inservice
programs
Observations:
Based on a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to ensure physical therapy staff appropriately re-evaluated the patient's level of function in order to revise the plan of care as necessary.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag 1026. A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant policies/procedures (already in place) were reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey Educated the service staff by reviewing the POC and treatment plans. Reviewed 'Home Care Guidelines pertaining to discharge'. Reviewed VO policy. with physician orders for compliance. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of discharge. E) Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Governing Board. Completion Date: 09/09/2017. Addendum: The new therapy staff during their orientation will be given the Medicare rules and regulations for therapy services, also orientation of Agency's own policies and procedures, and the agencies own guidelines for home care. Each new therapist will sign and date the orientation thus given and that will be kept on file. Each therapy visit is going to be monitored every week for a month and then every other week for a month. Monitored by: Administrator. Completion Date 09/09/2017." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (ensuring physical therapy staff appropriately re-evaluated the patient's level of function in order to revise the plan of care as necessary).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). Additionally, EMP1 revealed that there was no therapy staff hired or under contract. When asked why the agency does not have any therapy staff, EMP1 stated "With no patients coming in, its difficult to find staff and even agree to an interview." When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to ensuring physical therapy staff appropriately re-evaluated the patient's level of function in order to revise the plan of care as necessary, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17
Plan of Correction:An approved Plan of Correction is not on file.
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:
Per the Pennsylvania Nurse Practice Act, "... RESPONSIBILITIES OF THE REGISTERED NURSE...21.11. General functions. (a) The registered nurse assesses human responses and plan, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of the following functions: (1) collects complete and ongoing data to determine nursing care needs...21.18. Standards of nursing conduct. (1) a registered nurse shall:...(5) Document and maintain accurate records. (b) A registered nurse may not:...(8) Falsify or knowingly make incorrect entries into the patient's record or other related documents..."
Based on a review of the agency's written plan of correction, agency chart review monitoring tools provided during prior and current survey, and agency staff meeting documentation, and staff (EMP) interview, the agency failed to fully implement the plan of correction to ensure the agency maintained accurate, complete clinical records in accordance with agency policy and the Pennsylvania Nurse Practice Act.
Findings Included:
A review of the agency's written plan of correction during pre-survey preparation on 9/28/17 at approximately 10:00 a.m. revealed "Tag 1035. A combined meeting of the staff, Board of Governors' members of the G.O P.P was held on 08/30/17. Attendance sheet signed and dated. The deficiencies in the 'Statement of deficiencies' (SOD) pertaining to this Tag were studied along with the relevant policies/procedures (already in place) were reviewed. The Plan of Correction: Relevant charts were reviewed for this tag to look at the findings of the survey. Reviewed duties of a registered nurse. Reviewed job description of the registered nurse. Reviewed the Retention and maintenance of Clinical records. Educated the service staff by reviewing the POC and treatment plans. Reviewed VO policy. Reviewed Wound care policy. Reviewed guidelines regarding "Change in medical condition of the patient policy'. Reinforced to set short and long term goals. Educated by doing a walk through the POC (485). Educated and by going over the Medicare guidelines regarding measurable goals and setting short term goals and longtime goals to achieve a timely discharge of the patient. Reviewed agency's policy on Conformance with physician orders for compliance. Tools for monitoring to be used: The 'Self Audit' sheet which each service provider will use for each patient. Active Chart Review tool will be used while the patient is still on service. Closed Chart Review will be used at time of discharge. E) Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file. Monitored by: Administrator. Completion Date: 09/09/2017. Addendum: The staff was reeducated on 'Policies on 08/30/2017. The chart reviewed during the survey were of patients that had been all discharged. The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months. Monitored by: Governing Board. Completion Date: 09/09/2017. Addendum: The policies reviewed were the discharge policies, VO policy, Retention of Clinical records, Maintenance of clinical records. Completion Date: 09/09/2017. Monitored by: Administrator and Governing Body." Corrective action date (agency-identified date of alleged compliance) 9/16/17.
A review of agency staff meeting documentation on 9/27/17 at approximately 11:00 a.m. revealed "[agency name] COMBINED MEETING MINUTES HELD ON AUGUST 30th 2017 ... Page 1 of 3 ... In the beginning of the meeting the reason for the gathering was reiterated i.e. to discuss the 'statement of deficiencies' as posted on the DOH [department] website for our facility and to come up with the 'Plan of Correction'. The deficiencies' [sic] which consisted of Condition level deficiencies & standard deficiencies ... Page 3 of 3. ... Submitted by: [listed EMP7 with a signed date of 9/5/17]." It should be noted that additional signatures were found on the bottom of page 3 to include EMP1 with a signed date of 9/5/17, EMP9 with a signed date of 9/5/17, EMP3 with a signed date of 9/6/17, EMP8 with a signed date of 9/6/17, and EMP5 with a signed date of 9/24/17. All signature dates were after the 8/30/17 date identified in the plan of correction, and the 9/24/17 signature date from EMP5 was after the completion date of 9/16/17. Additionally, there was another sign-in sheet for this meeting provided by the agency for surveyor review that listed the signatures of EMP1, EMP9, EMP3, EMP7, and EMP8, but the dates of signature by the EMPs was not documented.
A review of the agency chart review monitoring tools on 9/29/17 at approximately 11:05 a.m. revealed three (3) separate tools titled "SELF AUDIT HELP SHEET," "Quarterly Active Chart Review," and "Quarterly Closed Chart Review." A further review of the tools revealed they were the same monitoring tools that were provided to surveyor during prior survey completed 8/16/17 with no changes to allow for more detailed monitoring specifically related to correcting the deficiencies cited (ensuring the agency maintained accurate, complete clinical records in accordance with agency policy and the Pennsylvania Nurse Practice Act).
An interview with EMP1 on 9/29/17 at approximately 11:10 a.m. revealed when asked why the agency monitoring tools remained unchanged and did not specifically address the deficiencies cited, EMP1 stated "I actually think that we need to understand that the entire plan is under the supervision of the physician and it is the physician's responsibility to ensure that the 485 [plan of care] is complete."
An interview with EMP1 on 9/29/17 at approximately 10:00 a.m. also revealed that the agency had no active patients and had not admitted any new patients since the exit date of the previous survey (8/16/17). When asked, without any active patients, how the agency can show full implementation of the plan of correction referring specifically to ensuring the agency maintained accurate, complete clinical records in accordance with agency policy and the Pennsylvania Nurse Practice Act, EMP1 stated "Those are the difficulties we are working, we are not sitting."
Repeat deficiency 8/16/17, 2/12/14
Plan of Correction:Tag 1035.
Since the State tags match the Federal tags, these State POC's are being submitted per federal tag rejection directives.
This POC is being resubmitted as per recent rejection reasons box directive i.e.
Other: The Department has updated your Federal 2567 and removed the Governoring Body Condition and related deficiencies. Please Resubmit Plan of Correction.
POC submitted 11/06/2017. This POC is in response to the third 'SOD' (2567) posted this morning for the same survey conducted on 09/29/2017.
The POC for this deficiency was submitted to the SA agency and was approved. We are committed to following that POC as it has kept us in substantial compliance. The new monitoring tools would be used to ensure that agency continues to strive towards perfection and in doing so to see that there is '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.
Completion Date: 10/27/2017.
Monitored by: Administrator.
Addendum:
This POC is for the resurvey done on 09/29/17. With the same tag deficiencies, we are resubmitting the POC.s for these tags already approved by the SA surveyor on 09/25/17. We are going to implement the same 'POC'for the new patients referrals we get.
Referral of patients to any home care agency is strictly based on patient's choice. We have no control of that. We ask friends/ neighbors and relatives to choose our agency, but it again is dependent upon patient's choice.
The overall 'POC' approved by the surveyors in September 2017 is being implemented.
A combined meeting held of staff, Board of Governors' members of the G.O P.P in August 2017
The Clinical Record deficiencies in the (SOD) pertaining to each Tag were studied along with the relevant policies/procedures (already in place) were reviewed.
Maintenance of 'Clinical records was studied to ensure that 'A clinical record containing pertinent past and current findings in accordance with accepted professional standards is maintained for every patient receiving home health services. In addition to the plan of care, the record contains appropriate identifying information; name of physician; drug, dietary, treatment, and activity orders; signed and dated clinical and progress notes; copies of summary reports sent to the attending physician; and a discharge summary'.
The Plan of Correction: Relevant charts were reviewed for deficiencies in each tag to look at the findings of the survey.
Educated the service staff by reviewing the POC and treatment plans.
Reviewed VO policy.
Reviewed Wound care policy.
Reviewed guidelines regarding "Change in medical condition of the patient policy'.
Drug regimen review.
Educated by doing a walk through the POC (485) and the 'Plan Of Treatment' and its periodic review.
Reviewed agency's policy on Conformance with physician orders for compliance.
Duties if the 'Registered Nurse'.
Therapy guidelines were looked at.
Discharge Policy.
Tools for monitoring to be used:
The 'Self Audit' sheet which each service provider will use for each patient.
Active Chart Review tool will be used while the patient is still on service.
Closed Chart Review will be used at time of discharge.
E) Monitoring: Chart monitoring is to be done by Self Audit starting 09/16/2017 and monitored by the Administrator. Self-Audit and Self-Monitoring to be done at each visit for a month. The Administrator will also do the Active chart review every week for a month, and then every other week for month and then upon discharge as a closed chart review. The chart review completed will be kept on file.
Monitored by: Administrator.
Completion Date: 10/27/2017
Addendum: The staff was reeducated on 'Policies on 08/30/2017.
The chart reviewed during the survey were of patients that had been all discharged.
The summary of results for the new patients will be forwarded to the GOPP and GB to monitor completion every month for two months.
Monitored by: Governing Board.
Completion Date: 10/27/2017
|