QA Investigation Results

Pennsylvania Department of Health
ADVANTAGE HOME HEALTH SERVICES, LLC
Health Inspection Results
ADVANTAGE HOME HEALTH SERVICES, LLC
Health Inspection Results For:


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Initial Comments:


Based on the findings of an unannounced onsite Medicare Re-certification survey completed February 19, 2021, Advantage Home Health Services, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.








Plan of Correction:




484.60(a)(2)(i-xvi) ELEMENT
Plan of care must include the following

Name - Component - 00
The individualized plan of care must include the following:
(i) All pertinent diagnoses;
(ii) The patient's mental, psychosocial, and cognitive status;
(iii) The types of services, supplies, and equipment required;
(iv) The frequency and duration of visits to be made;
(v) Prognosis;
(vi) Rehabilitation potential;
(vii) Functional limitations;
(viii) Activities permitted;
(ix) Nutritional requirements;
(x) All medications and treatments;
(xi) Safety measures to protect against injury;
(xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors.
(xiii) Patient and caregiver education and training to facilitate timely discharge;
(xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient;
(xv) Information related to any advanced directives; and
(xvi) Any additional items the HHA or physician or allowed practitioner may choose to include.

Observations:


Based on review of agency Policy, clinical record (CR) review and staff (EMP) interview, it was determined that the agency failed to ensure the Plan of Care (POC) contained all disciplines ordered on the referral for two (2) of fourteen (14) CR reviewed. (CR 2 &12). The agency also failed o ensure the POC contained ordered nterventions for one (1) of fourteen (14) CR reviewed (CR5), and supplies for one (1) of fourteen (14) CR reviewed (CR4.)


Findings included:

Review of agency policy on February 18, 2021 at approximately 11:45 am revealed: "Plan of Care-CMS #485 and Physician Orders...Procedure...4. The individualized plan of care must include the following:...The types of services, supplies, and equipment" required...

Review of clinical records on February 12, 2021 between approximately 9:25am and 11:30am, February 16, 2021 between approximately 8:30 am and 2:30 pm, and February 18, 2021 between approximately 1:20 pm and 3:30 pm, and January 8, 2021 between approximately 10:00 am and 11:30 am revealed:

CR2, start of service (SOS)1/17/2021, period reviewed 1/17/2021-2/11/2021, CR contained referral to Home Health Agency for aftercare following joint replacement for Nursing, Physical Therapy and Occupational Therapy. Plan of Care (POC) developed upon intial comprehensive assessment did not include Occupational Therapy (OT). No evidence that OT was ordered to evaluate patient.
CR4, SOS 1/30/2021, period reviewed 1/30/2021-3/30/2021, CR contained referral to Home Health Agency ordering Accuchecks (blood glucose testing) fout times a day. Plan of CAre (POC) developed upon initial comprehensive assessment also ordered Accuchecks four times a day. No diabetic testing supplies documented on POC.
CR5, SOS 2/1/2021, period reviewed 2//2021-4/1/2021, CR revealed POC documentation of Sliding scale insulin to be administered three times a day. Intervention on POC documented "Blood sugar checks as needed per day." Narrative note written by nurse upon initial comprehensive assessment noted staff at facility check blood sugar. POC failed to contain intervention for caregiver to check blood glucose level three times a day to coorelate with sliding scale insulin administration.
CR12, SOS 1/18/2021, period reviewed 1/18/2021-2/6/2021, CR contained referral to Home Health Agency for Nursing, Physical Therapy, and Occupational Therapy services. Plan of Care (POC) developed upon intial comprehensive assessment did not include Occupational Therapy (OT). No evidence that OT was ordered to evaluate patient.
Findings confirmed in exit interview with Vice President of Quality, Vice President of Operations, and Chief Financial Officer on 2/18/2021 at approximately 12:30 pm confirmed findings.










Plan of Correction:

The Vice President of Clinical Operations/VP of Quality will review with staff the importance of having all required elements on the POC ie all supplies/DME and appropriate interventions on 3/2/2021. Will review with staff that all disciplines ordered by MD upon referral are addressed on POC on 3/2/2021. All evaluating staff will be presented with POC policy. The VP of Quality Assurance and Utilization Management will audit charts weekly beginning week of 3/1/2021 to ensure that all staff have required POC elements ie all supplies/DME and appropriate interventions on the 485 and that all disciplines ordered at time of referral are addressed on POC. A weekly audit log will be maintained by the VP of QA and UM until week ending 4/24/2021 and then will be incorporated into quarterly QAPI audits for continued monitoring


484.60(b)(3)(4) ELEMENT
Verbal orders

Name - Component - 00
(3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies.

(4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies.

Observations:


Based on review of agency policy, clinical records (CR), and staff (EMP) interview, it was determined that the agency failed to ensure verbal orders were signed and dated by ordering physician within 7 days for five (5) of fourteen (14) CR's reviewed. (CR 4, 7, 11, 12, &13)
Findings included:
Review of agency policy on February 18, 2021 at approximately 11:45 revealed Agency policy to not reflect Pennsylvania State Regulations for physician signature of verbal orders. Policy reads: " Physician Orders-Verbal Orders ...PROCEDURE ...All verbal orders must be subsequently signed by the physician (withing 30 days for CHAP) ... "
Interview with Vice Presidency of Operations on February 18, 2021 at approximately 12:00pm revealed that the agency " does not have a formal process for obtaining physician signatures on orders but we usually fax it out once signed by the clinician and if not received back in 5 days we refax it out. "
Review of clinical records on February 12, 2021 between approximately 9:25 am and 11:30 am, February 16, 2021 between approximately 8:30 am and 2:30 pm, and February 18, 2021 between approximately 1:20 pm and 3:30 pm, and January 8, 2021 between approximately 10:00 am and 11:30 am revealed:
CR4, start of services (SOS) 1/30/2021, period reviewed 1/30/2021-3/30/2021, CR contained Plan of Care (POC) with a verbal order date signed by Registered Nurse (RN) on 1/30/2021. As of 2/18/2021 POC not back signed by physician. Documentation reflected POC sent for to physician for signature 2/2/2021 and 2/16/2021. No evidence of multiple attempts to obtain signature within 7 days of receipt of verbal order.
CR7, SOS 6/3/2020, period reviewed 11/30/2020-1/28/2021, CR contained Plan of Care (POC) with a verbal order date signed by Registered Nurse (RN) on 1/15/2021. Doctor signature on POC dated 1/27/2021. No evidence of multiple attempts to obtain signature within 7 days of receipt of verbal order.
CR11, SOS 2/29/2020, period reviewed 2/29/2020-3/12/2020, CR contained Plan of Care (POC) with a verbal order date signed by Registered Nurse (RN) on 2/29/2020. Doctor signature on POC dated 3/11/2020. No evidence of multiple attempts to obtain signature within 7 days of receipt of verbal order.
CR12, SOS 1/18/2021, period reviewed 1/18/2021-2/6/2021, CR contained Plan of Care (POC) with a verbal order date signed by Registered Nurse (RN) on 1/18/2021. Doctor signature on POC dated 1/27/2021. No evidence of multiple attempts to obtain signature within 7 days of receipt of verbal order.
CR13, SOS 7/23/2020, period reviewed 7/23/2020-8/7/2020, CR contained Plan of Care (PC) with a verbal order date signed by Registered Nurse (RN) on 7/23/2020. As of 2/18/2021, No physician signature on POC. Documentation reflects POC sent to physician 7/24/2020, 7/30/2020, then monthly for five months 8/14/2020, 9/29/2020, 10/15/2020, 11/16/2020, 12/28/2020, with no evidence of attempts in 2021.
Findings confirmed in exit interview with Vice President of Quality, Vice President of Operations, and Chief Financial Officer on 2/18/2021 at approximately 12:30 pm confirmed findings.







Plan of Correction:

The Vice President of Clinical Operations/VP of Quality will create an orders process and review with orders management team on 3/2/2021 will discuss the importance of numerous attempts to obtain within 7 days these attempts could include faxing, phone calls and or liaison pick up and documentation of every attempt will be documented in the EMR. Will also review the importance of ongoing attempts greater than 7 days in order to make every effort to obtain getting orders back signed by day 30. Weekly audit log will be maintained by the VP of QA and UM until 4/24/2021 and then will be incorporated into quarterly QAPI audits.


Initial Comments:



Based on the findings of an unannounced onsite Medicare Re-certification survey completed February 19, 2021, Advantage Home Health Services, was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Condition of Participation: Home Health Agencies- Emergency Preparedness.





Plan of Correction:




Initial Comments:


Based on the findings of an unannounced onsite relicensure survey completed February 19, 2021, Advantage Home Health Services, was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health, Subpart G. Chapter 601.









Plan of Correction:




601.31(b) REQUIREMENT
PLAN OF TREATMENT

Name - Component - 00
601.31(b) Plan of Treatment. The
plan of treatment developed in
consultation with the agency staff
covers all pertinent diagnoses,
including:
(i) mental status,
(ii) types of services and equipment
required,
(iii) frequency of visits,
(iv) prognosis,
(v) rehabilitation potential,
(vi) functional limitations,
(vii) activities permitted,
(viii) nutritional requirements,
(ix) medications and treatments,
(x) any safety measures to protect
against injury,
(xi) instructions for timely
discharge or referral, and
(xii) any other appropriate items.
(Examples: Laboratory procedures and
any contra-indications or
precautions to be observed).

If a physician refers a patient under
a plan of treatment which cannot be
completed until after an evaluation
visit, the physician is consulted to
approve additions or modifications to
the original plan.

Orders for therapy services include
the specific procedures and modalities
to be used and the amount, frequency,
and duration.
The therapist and other agency
personnel participate in developing
the plan of treatment.

Observations:


Based on review of agency Policy, clinical record (CR) review and staff (EMP) interview, it was determined that the agency failed to ensure the Plan of Care (POC) contained all disciplines ordered on the referral for two (2) of fourteen (14) CR reviewed. (CR 2 &12); failed to ensure the POC contained ordered interventions for one (1) of fourteen (14) CR reviewed (CR5), and supplies for one (1) of fourteen (14) CR reviewed (CR4.)

Findings included:
Review of agency policy on February 18, 2021 at approximately 11:45 revealed: "Plan of Care-CMS #485 and Physician Orders...Procedure...4. The individualized plan of care must include the following:...The types of services, supplies, and equipment" required...
Review of clinical records on February 12, 2021 between approximately 9:25 am and 11:30 am, February 16, 2021 between approximately 8:30 am and 2:30 pm, and February 18, 2021 between approximately 1:20 pm and 3:30 pm, and January 8, 2021 between approximately 10:00 am and 11:30 am revealed:

CR2, start of service (SOS)1/17/2021, period reviewed 1/17/2021-2/11/2021, CR contained referral to Home Health Agency for aftercare following joint replacement for Nursing, Physical Therapy and Occupational Therapy. Plan of Care (POC) developed upon intial comprehensive assessment did not include Occupational Therapy (OT). No evidence that OT was ordered to evaluate patient.
CR4, SOS 1/30/2021, period reviewed 1/30/2021-3/30/2021, CR contained referral to Home Health Agency ordering Accuchecks (blood glucose testing) four times a day. Plan of Care (POC) developed upon initial comprehensive assessment also ordered Accuchecks four times a day. No diabetic testing supplies documented on POC.
CR5, SOS 2/1/2021, period reviewed 2//2021-4/1/2021, CR revealed POC documentation of Sliding scale insulin to be administered three times a day. Intervention on POC documented "Blood sugar checks as needed per day." Narrative note written by nurse upon initial comprehensive assessment noted staff at facility check blood sugar. POC failed to contain intervention for caregiver to check blood glucose level three times a day to correlate with sliding scale insulin administration.
CR12, SOS 1/18/2021, period reviewed 1/18/2021-2/6/2021, CR contained referral to Home Health Agency for Nursing, Physical Therapy, and Occupational Therapy services. Plan of Care (POC) developed upon intial comprehensive assessment did not include Occupational Therapy (OT). No evidence that OT was ordered to evaluate patient.
Findings confirmed in exit interview with Vice President of Quality, Vice President of Operations, and Chief Financial Officer on 2/18/2021 at approximately 12:30 pm confirmed findings.









Plan of Correction:

The Vice President of Clinical Operations/VP of Quality will review with staff the importance of having all required elements on the POC ie all supplies/DME and appropriate interventions on 3/2/2021. Will review with staff that all disciplines ordered by MD upon referral are addressed on POC on 3/2/2021. All evaluating staff will be presented with POC policy. The VP of Quality Assurance and Utilization Management will audit charts weekly beginning week of 3/1/2021 to ensure that all staff have required POC elements ie all supplies/DME and appropriate interventions on the 485 and that all disciplines ordered at time of referral are addressed on POC. A weekly audit log will be maintained by the VP of QA and UM until week ending 4/24/2021 and then will be incorporated into quarterly QAPI audits for continued monitoring


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 review of agency policy, clinical records (CR), and staff (EMP) interview, it was determined that the agency failed to ensure verbal orders were signed and dated by ordering physician within 7 days for five (5) of fourteen (14) CR's reviewed. (CR 4, 7, 11, 12, &13)
Findings included:
Review of agency policy on February 18, 2021 at approximately 11:45 revealed Agency policy to not reflect Pennsylvania State Regulations for physician signature of verbal orders. Policy reads: " Physician Orders-Verbal Orders ...PROCEDURE ...All verbal orders must be subsequently signed by the physician (withing 30 days for CHAP) ... "
Interview with Vice Presidency of Operations on February 18, 2021 at approximately 12:00pm revealed that the agency " does not have a formal process for obtaining physician signatures on orders but we usually fax it out once signed by the clinician and if not received back in 5 days we refax it out. "
Review of clinical records on February 12, 2021 between approximately 9:25 am and 11:30 am, February 16, 2021 between approximately 8:30 am and 2:30 pm, and February 18, 2021 between approximately 1:20 pm and 3:30 pm, and January 8, 2021 between approximately 10:00a m and 11:30 am revealed:
CR4, start of services (SOS) 1/30/2021, period reviewed 1/30/2021-3/30/2021, CR contained Plan of Care (POC) with a verbal order date signed by Registered Nurse (RN) on 1/30/2021. As of 2/18/2021 POC not back signed by physician. Documentation reflected POC sent for to physician for signature 2/2/2021 and 2/16/2021. No evidence of multiple attempts to obtain signature within 7 days of receipt of verbal order.
CR7, SOS 6/3/2020, period reviewed 11/30/2020-1/28/2021, CR contained Plan of Care (POC) with a verbal order date signed by Registered Nurse (RN) on 1/15/2021. Doctor signature on POC dated 1/27/2021. No evidence of multiple attempts to obtain signature within 7 days of receipt of verbal order.
CR11, SOS 2/29/2020, period reviewed 2/29/2020-3/12/2020, CR contained Plan of Care (POC) with a verbal order date signed by Registered Nurse (RN) on 2/29/2020. Doctor signature on POC dated 3/11/2020. No evidence of multiple attempts to obtain signature within 7 days of receipt of verbal order.
CR12, SOS 1/18/2021, period reviewed 1/18/2021-2/6/2021, CR contained Plan of Care (POC) with a verbal order date signed by Registered Nurse (RN) on 1/18/2021. Doctor signature on POC dated 1/27/2021. No evidence of multiple attempts to obtain signature within 7 days of receipt of verbal order.
CR13, SOS 7/23/2020, period reviewed 7/23/2020-8/7/2020, CR contained Plan of Care (PC) with a verbal order date signed by Registered Nurse (RN) on 7/23/2020. As of 2/18/2021, No physician signature on POC. Documentation reflects POC sent to physician 7/24/2020, 7/30/2020, then monthly for five months 8/14/2020, 9/29/2020, 10/15/2020, 11/16/2020, 12/28/2020, with no evidence of attempts in 2021.
Findings confirmed in exit interview with Vice President of Quality, Vice President of Operations, and Chief Financial Officer on 2/18/2021 at approximately 12:30 pm confirmed findings.











Plan of Correction:

The Vice President of Clinical Operations/VP of Quality will create an orders process and review with orders management team on 3/2/2021 will discuss the importance of numerous attempts to obtain within 7 days these attempts could include faxing, phone calls and or liaison pick up and documentation of every attempt will be documented in the EMR. Will also review the importance of ongoing attempts greater than 7 days in order to make every effort to obtain getting orders back signed by day 30. Weekly audit log will be maintained by the VP of QA and UM until 4/24/2021 and then will be incorporated into quarterly QAPI audits.


Initial Comments:


Based on the findings of an unannounced onsite relicensure survey completed February 19, 2021, Advantage Home Health Services, was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.








Plan of Correction:




Initial Comments:



Based on the findings of an unannounced onsite relicensure survey completed February 19, 2021, Advantage Home Health Services, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).







Plan of Correction: