Initial Comments:
Based on the findings of an unannounced on-site home health agency state re-licensure survey conducted November 20, 2023, and concluded off-site on November 28, 2023, Nursing Care Services, Inc. was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health facilities, Subpart G. Chapter 601.
Plan of Correction:
601.21(f) REQUIREMENT
PERSONNEL POLICIES
Name - Component - 00
601.21(f) Personnel Policies.
Personnel practices and patient care
are supported by appropriate, written
personnel policies. Personnel records
include qualifications, licensure,
performance evaluations, health
examinations, documentation of
orientation provided, and job
descriptions, and are kept current.
Observations:
Based on review of agency policies, personnel files (PF) and interview with the agency Administrator, the agency failed to include required documentation in the PF for eight (8) of eight (8) PF reviewed. (PF # 1, 2, 3, 4, 5, 6, 7, and 8).
Findings include:
Review of "Employee Handbook And Employment Orientation and Policies" on November 28, 2023, at approximately 10:30 A.M. revealed a table titled "Criminal Records" which listed the following requirements:
"State Police - All New Employees - Annually
Child Abuse Check - All who work directly with children - Annually"
A table titled "Basic Credentials" listed the following requirements:
"PPD test - All positions - Annually
CPR - RN and LPN - 1-2 years
Hepatitis B- All Positions - One Time Only"
The CDC (Centers for Disease and Control and Prevention) guidelines state baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or tuberculin skin test (TST), shall include a symptom screen questionnaire and an individual tuberculosis (TB) risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
Review of PF on November 20, 2023, from approximately 1:00 P.M. to 2:30 P.M. revealed the following:
PF #1, date of hire February 14, 2018, did not contain a child abuse clearance, a skills/competency checklist upon hire, documentation of Hepatitis B vaccine or declination, initial TB testing on hire, a TB symptom screening questionnaire and TB risk assessment upon hire, and annual TB education in 2019 through 2023. There was documentation of a single TST completed on March 28, 2023. There was no documentation of a second TST completed.
PF #2, date of hire March 3, 2011, did not contain documentation of a TB symptom screening questionnaire and TB risk assessment completed in 2019 when the CDC guideline were updated, and no annual TB education for 2019 through 2023.
PF #3, date of hire September 22, 2023, did not contain documentation of a skills/competency assessment completed upon hire, Hepatitis B vaccine or declination, initial TB testing on hire, a TB symptom screening questionnaire and TB risk assessment upon hire.
PF #5, date of hire November 1, 2022, did not contain documentation of a criminal background check completed upon hire, initial competency/skills assessment completed upon hire, initial TB testing on hire, a TB symptom screening questionnaire and TB risk assessment upon hire.
PF #6, date of hire December 6, 2016, did not contain documentation of a TB symptom screening questionnaire and TB risk assessment completed in 2019 when the CDC guideline were updated, and no annual TB education for 2019 through 2023.
PF #7, date of hire December 1, 2014, did not contain documentation of a criminal background check completed on hire, documentation of a TB symptom screening questionnaire and TB risk assessment completed in 2019 when the CDC guideline were updated, and no annual TB education for 2019 through 2023.
PF #8, date of hire December 27, 2007, did not contain documentation of a current CPR certification, documentation of a TB symptom screening questionnaire and TB risk assessment completed in 2019 when the CDC guideline were updated, and no annual TB education for 2019 through 2023.
An interview with the agency Administrator on November 20, 2023, at approximately 3:00 P.M. confirmed the above findings. Subsequent email communications on November 27, 2023, and November 28, 2023, confirmed the above findings.
Plan of Correction:POC 1001
The CDC (Centers for Disease Control) guidelines for TB and TB screening will be implemented into NCS's annual screening guidelines, including symptom screen questionnaire and individual tuberculosis risk assessment. Although the CDC does not recommend Serial Screening routinely, our LTCs (Long Term Care) still require yearly PPDs, therefore we will follow the DOH (Department of Health) CDC guidelines with appropriate screening, but we will also be doing Serial Screening for all our LTC (Long Term Care) staff.
NCS's Hep B declination form is a part of our Handbook and our signature page. Nobody is hired without filling out the Hep B form. NCS will add a separate Hep B form for our Home Health Facility license employees and contractors and will have it displayed appropriately in the file. HR Manager will be responsible for maintaining separate files for all DOH patients.
All RN (REGISTERED NURSE), LPN (Licensed Practical Nurse), CNA (Certified Nursing Assistant) and DCS will fill out a skills checklist. NCS's HR (Human Resources) department has reinstituted the skills checklist for all staff. HR has audited all files to ensure that the required skills checklist and all the DOHs (Department of Health) (Department of Health) recommended documentation is in all the files.
All CBC's completed upon hire will be kept in perpetuity, until employment is ended and the required period for record retention is completed. NCS has been in business for 31 years. Many staff have worked for NCS for more than 20 years. Many files were purged, and the new hire dates were not given to DOH auditor appropriately. The administrator gave the original date of hire rather than rehire date. This would contribute to not having appropriate documentation.
CPR will be required at time of hire for all DOH Home health cases.
HR Manager will create checklists and protocols for hiring which include all the requirements by the DOH. All the forms that we had but didn't show DOH will be consolidated into separate files for every private duty personnel. At the initiation of any private case, all personnel utilized for the case will have all DOH required paperwork pulled and placed into a new employee folder for DOH employees only. HR Manager will pull a client list every week, per her job, to assure that all private duties and the personnel are within compliance.
HR Manager will implement the new CDC requirements from 2019 for TB. NCS will maintain yearly PPDs for all LTCs that require yearly PPDs although it's not a CDC requirement. NCS will add the CDC TB education and symptoms flyer with our yearly renewal of TB requirements. The CDC requirements for TB will be added to our NCS credential requirements. Our staff can't work if the SymplrCTM staffing program doesn't meet the requirements for staffing credentials in the program. A new CDC credential form for TB will be added to our staffing software for yearly renewal. All private duty personnel will have the forms in their files. No one can work for NCS when their credentials are out of compliance. HR Manager will monitor and report any issues or deviations to Administrator.
601.21(h) REQUIREMENT
COORDINATION OF PATIENT SERVICES
Name - Component - 00
601.21(h) Coordination of Patient
Services. All personnel providing
services maintain liason to assure
that their efforts effectively
complement one another and support the
objectives outlined in the plan of
treatment. (i) The clinical record
or minutes of case conferences
establish that effective interchange,
reporting, and coordinated patient
evaluation does occur. (ii) A
written summary report for each
patient is sent to the attending
physician at least every 60 days.
Observations:
Based on review of agency policy, clinical records (CR), and an interview with the agency Administrator, the agency failed provide documentation that a written summary was provided to the attending physician at least every 60 days for three (3) of seven (7) CR reviewed (CR# 1, 2, and 3).
Findings include:
A review of the agency policies on November 20, 2023, at approximately 2:45 P.M. revealed no policy addressing a written summary to be sent to the attending physician every 60 days.
A review of CR conducted on November 20, 2023, from approximately 10:30 A.M. to 1:00 P.M. revealed the following:
CR#1, start of care February 1, 2023, certification period August 1, 2023, through October 31, 2023, contained no documentation that a written summary was provided to the attending physician every 60 days.
CR#2, start of care March 23, 2023, certification period October 1, 2023, through November 30, 2023, contained no documentation that a written summary was provided to the attending physician every 60 days.
CR #3, start of care May 1, 2023, certification period November 1, 2023, through December 31, 2023, contained no documentation that a written summary was provided to the attending physician every 60 days.
An interview with the agency Administrator on November 20, 2023, at approximately 3:00 P.M. confirmed the above findings.
Plan of Correction:POC 1009
NCS changed the 60-day Home Health Certification and Plan of Care to include a written summary report for each patient sent to the attending physicians. All new 60-day Home Health Certification and Plan of Care will contain the patient care summary.
NCS will utilize our Task Function, in our staffing software, and our Calendar functions for all renewed 60-day POC. HR Manager will assist Administrator in implementing all checklists, policies, and procedures and adhering to appropriate dates of service for the POC. All POCs will be reviewed by both HR Manager and Administrator prior to being sent to the Physician of record. HR Manager will be responsible for tracking the return of the POC. If we don't receive the POC, HR manager will alert me in ample time, and I will intervene as an RN.
All Facility records of patients and staff caring for private duty cases will be held separately in a different filing cabinet. All documents to be returned within a specific time will be monitored by HR Manager to ensure adherence to the policies implemented.
HR Manager will be responsible for following up on all of the correspondence and auditing of the files with Administrator. HR Manager will keep a schedule of when documents need to be sent and received. Nursing Supervisor RN and Administrator RN will follow all the DOH rules and regulations and will review all the deficiencies with our staff!
601.22(d) REQUIREMENT
CLINICAL RECORD REVIEW
Name - Component - 00
601.22(d) Clinical Record Review. At
least quarterly, appropriate health
professionals, representing at least
the scope of the program, review a
sample of both active and closed
clinical records to assure that
established policies are followed in
providing services (direct as well as
services under arrangement). There is
a continuing review of clinical
records for each 60-day period that a
patient receives home health services
to determine adequacy of the plan of
treatment and appropriateness of
continuation of care.
Observations:
Based on review of agency policy, agency documents, and interview with the agency Administrator, the agency failed to conduct quarterly clinical record reviews.
Findings include:
Review of agency policy titled " 100.4 Quarterly Clinical Record Review Policy " on November 20, 2023, at approximately 2:45 P.M. stated, " At least quarterly, appropriate health professionals, representing at least the scope of the program, shall review a sample of both active and closed clinical records to assure that established policies are followed in providing services ... There shall be a continuing review of clinical records for each 60-day period that a patient received home health care services to determine adequacy of the plan of treatment and appropriateness of continuation of care. "
Review of agency documentation on November 20, 2023, at approximately 10:00 A.M. revealed quarterly meetings of the Professional Advisory Committee that presented an overview of active cases. There was no documentation of quarterly clinical record reviews of active and closed clinical records to ensure that established policies are followed in providing services, adequacy of the plan of treatment, and appropriateness of continuation of care.
An interview with the agency Administrator on November 20, 2023, at approximately 3:00 P.M. confirmed the above findings.
Plan of Correction:Quarterly Records Review and report: NCS will do quarterly record reviews on active and closed cases to assure that NCS is following all the DOH (Department of Health) rules and regulations. All POC and treatments along with the appropriateness of the plan of care will be included. HR Manager will assist in developing the checklist for DOH required documents, and personnelle files. DOH files for any employee or contractor will be held separately in a different filing cabinet with the appropriately
A quarterly review of all personnel files will be conducted during the quarterly client records review.
NCS will do an initial review of all files including client and employees to ensure all records are brought into compliance. This audit will commence the first – second week of January. NCS's HR manager, will assist in the implementation of checklists to make sure adherence to protocols and policies are adhered.
NCS will implement a checklist for both the clients and the personnel records associated with our DOH Home Health Facility License.
An initial check list of required documents, signatures, and initial meetings will be implemented for all new cases. This checklist will become a part of the permanent record of our clients and our employees. All efforts will be made to ensure compliance through written policy, procedures and checklists.
Any active cases prior to January 27th will be up to date will all required documentation. All cases from 2023 will be reviewed for deficiencies with my HR manager to develop tools to maintain compliance with DOH regulations.
601.31(a) REQUIREMENT
PATIENT ACCEPTANCE
Name - Component - 00
601.31(a) Patient Acceptance.
Patients are accepted for treatment on
the basis of a reasonable expectation
that the patient's medical, nursing
and social needs can be met adequately
by the agency in the patient's place
of residence. Care follows a written
plan of treatment established and
periodically reviewed by a physician
and care continues under the general
supervision of a physician.
Observations:
Based on a review of clinical records (CR), agency policy, and an interview with the agency Administrator, the agency accepted a patient for services for which the agency was unable to provide care, for one (1) of seven (7) CR reviewed (CR#6).
Findings include:
Review of agency policy titled "101.1 Acceptance of Patient Policy " conducted on November 20, 2023, at approximately 2:45 P.M. stated, " Patients shall be accepted for treatment on the basis of a reasonable expectation that the patient ' s medical, nursing and social needs can be met adequately by the agency in the patient ' s place of residence. Patients shall be accepted for treatment on the basis that a services agreement is signed and returned to Nursing Care Services, Inc .... Patient care shall follow a written plan of treatment established by the RN supervisor in through nursing assessment and communication directly with the attending physician ... "
Review of CR on November 20, 2023, from approximately 10:30 A.M. to 1:00 P.M. revealed the following:
CR #6, no start of care date identified. There was no documentation of a physician order to begin services. There was no documentation of an initial assessment completed by a registered nurse (RN). The only documentation provided was consultation reports by a pulmonologist (physician who manages respiratory disorders), a neurologist (physician who manages brain and nervous system disorders), and a nephrologist (physician who manages kidney disorders). Diagnoses include, but are not limited to, convulsions (seizure disorder), tracheostomy (tube inserted through the neck into the trachea), gastrostomy tube (tube inserted through abdomen into the stomach for administration of nutrition), and cerebral palsy (disorder that causes abnormal movement and muscle tone).
An interview with the agency Administrator on November 20, 2023, at approximately 11:00 A.M. revealed that the agency accepted the case (no start of care date provided) based on information provided by the family stating that the patient only required tube feedings. Care was being provided by a primary agency for most of the hours authorized by the payor source. The administrator stated that the RN provided care for two shifts, but determined that the agency would not be able to staff the case. The patient was discharged from service with the agency. There was no documentation of a "Home Health Certification and Plan of Care" (POC) signed by the physician, a verbal order for start of care, documentation of services provided, a discharge order (no discharge date noted), or a discharge summary provided to the physician.
An interview with the administrator on November 20, 2023, at approximately 3:00 P.M. confirmed that the agency accepted a patient for services that the agency was not able to provide.
Plan of Correction:No cases or new clients will be accepted prior to an initial meeting and signing of documents. NCS will do its due diligence to ensure that NCS is an appropriate staffing solution for every new client. Any clients that are above our skill set or are outside our skill set will be referred to the appropriate agency. A complete medical history will be obtained prior to accepting any new clients.
Nursing Supervisor RN will not accept any cases prior to an in-person evaluation for appropriateness of client. The Nursing Supervisor will do the initial evaluation prior to the acceptance of any new case.
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 records (CR) and an interview with the agency administrator, the agency failed to ensure an acceptable plan of treatment was in place for seven (7) of seven (7) CR reviewed. (CR # 1, 2, 3, 4, 5, 6, and 7).
Finding included:
Review of agency policy titled " 101.3 Plan of Treatment Policy " on November 20, 2023, at approximately 2:45 P.M. stated, " The plan of treatment shall be developed in consultation with the agency staff and shall cover 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, safety measures to protect against injury, instructions for timely discharge or referral and other appropriate items. If an attending physician refers a patient under a plan of treatment, which cannot be completed until after an evaluation visit, the attending physician shall be consulted to approve additions or modifications to the original plan ... "
Review of CR on November 20, 2023, from approximately 10:30 A.M. to 1:00 P.M. revealed the following:
CR #1, start of care February 1, 2023. Certification period reviewed: August 1, 2023, through October 31, 2023. Diagnosis: Pain, cellulitis right lower leg. The " Home Health Certification and Plan of Care " (POC) did not contain medication dosage, route, and frequency, DME (durable medical equipment) and supplies, nutritional requirements, and orders for discipline and treatments that include the discipline of the staff providing services, the frequency and duration of services, and specific orders for care to be provided.
CR #2, start of care March 23, 2023. Certification period reviewed: October 1, 2023, through December 31, 2023. Diagnosis: Post bowel resection, colostomy. The POC did not contain medication name, dosage, route, and frequency, DME and supplies, functional limitations, activities permitted, and orders for discipline and treatments that include the discipline of the staff providing services, the frequency and duration of services, and specific orders for care to be provided.
CR #3, start of care May 1, 2023. Certification period reviewed: November 1, 2023, through December 31, 2023. Diagnosis: Inability to void/constipation. The POC did not contain medication name, dosage, route, and frequency, catheter type/size, and orders for discipline and treatments that include the discipline of the staff providing services and duration of services, and specific orders for care to be provided.
CR #4, start of care October 25, 2023. Certification period reviewed: No dates provided. Diagnosis: Total knee right. The POC did not contain medication name, dosage, route and frequency, DME and Supplies, discipline of the staff providing services, and duration of services.
CR #5, start of care October 24, 2023. Certification period reviewed: October 24, 2023, through November 7, 2023. Diagnosis: Pneumonia, bacterial infection. The POC did not contain DME and supplies for PICC (peripherally inserted central catheter/intravenous catheter) line dressing changes, safety measures, the discipline of the staff providing services and the duration of services, a specific physician responsible for the POC, and a physician ' s signature and date.
CR #6 did not contain a start of care date, physician ' s orders for care, including medications.
CR #7, start of care November 2, 2023, per admission documents. There was no documentation of physician's orders for care.
An interview with the agency Administrator on November 20, 2023, at approximately 3:00 P.M. confirmed the above findings.
Plan of Correction:All plan of treatments developed shall cover all pertinent diagnosis, 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 appropriate items including laboratory procedures and any contraindications or precautions to be observed. Physicians referring clients for service shall be included in the initial evaluation if there are any additions or adaptations needed. All aspects of the patient's care including current and past diagnoses, all pertinent information including medications, any modalities for wellness, treatments, frequency and any pertinent patient information based on nursing protocols and standards. All current patients will have a new POC created with all the stated changes.
A standardized POT form will be implemented as a part of our policies and procedures. The POT will include all the areas that need to be filled in to use for a referral. HR manager, will assist in the implementation of the standardized POT form. All POT forms filled out will be checked and rechecked by Administrator and HR Manager to ensure compliance.
NCS will follow all the RN laws and DOH Facility License requirements for all POTs, including but not limited to the areas listed above. All regulations will be followed and adhered to. NCS will review all POTs prior to sending out, to make sure it contains all the requirements needed to be in compliance.
NCS will review the charts and employees' files quarterly to make sure we're in total compliance with all DOH facility laws and regulations.
601.31(c) REQUIREMENT
PERIODIC REVIEW OF PLAN OF TREATMENT
Name - Component - 00
601.31(c) Periodic Review of Plan of
Treatment. The total plan of
treatment is reviewed by the attending
physician and agency personnel as
often as the severity of the patient's
condition requires, but at least once
every 60 days. Agency professional
staff promptly alert the physician to
any changes that suggest a need to
alter the plan of treatment
Observations:
Based on a review of clinical records (CR), agency policy and an interview with the agency Administrator, the agency did not provide a review of the total plan of treatment by the attending physician and agency personnel at least every sixty (60) in accordance with agency policy for seven (7) of seven (7) CR reviewed (CR # 1, 2, 3, 4, 5, 6, and 7).
Findings include:
A review of agency policy " 101.4 Periodic review of Plan of Treatment Policy " on November 20, 2023, at approximately 2:45 P.M. stated, " The total plan of treatment shall be reviewed by the attending physician and home health care agency personnel as often as the severity of the patient ' s condition requires, but at least one every 60 days ... "
A review of CR conducted on November 20, 2023, from approximately 10:30 A.M. to 1:00 P.M. revealed the following:
CR #1, start of care February 1, 2023, contained a "Home Health Certification and Plan of Care" (POC) with certification periods as follows: February 1, 2023, through April 30, 2023, (89 days), May 1, 2023, through July 31, 2023, (92 days), and August 1, 2023, through October 31, 2023, (92 days).
CR #2, start of care March 23, 2023, contained a POC with certification periods as follows: March 23, 2023, through May 31, 2023, (70 days), June 1, 2023, through July 30, 2023, (no orders for July 31, 2023), August 1, 2023, through September 30, 2023, (61 days), and October 1, 2023, through November 30, 2023, (61 days).
CR #3, start of care May 1, 2023, contained a POC with certification periods as follows: May 1, 2023, through June 30, 2023, (61 days), July 1, 2023, through August 30, 2023, (61 days, no orders for August 31, 2023), September 1, 2023, through October 30, 2023, (no orders for October 31, 2023), and November 1, 2023, through December 31, 2023, (61 days).
CR #4, start of care October 25, 2023, contained a POC with no certification dates noted.
CR #6, no start of care date noted, contained no POC.
CR #7, no start of care date noted, contained no POC.
An interview with the agency Administrator on November 20, 2023, at approximately 3:00 P.M. confirmed the above findings.
Plan of Correction:
All Plan of Treatments will be reviewed by the attending physician and agency personnel as often as the severity of the patient's condition but no more than a 60-day period. Any changes in the patient's status will result in a new POT requiring a physician's signature. All POT will adhere to the 60-day period or sooner based on the patients' changes.
All nurses' notes from all active cases will be due the week of the treatment and the service. All nurses' notes will be sent to Administrator for review weekly. Payroll manager will be responsible for providing the documentation received by the nurses doing private duties. Office Staffing Manager will have an active list of all active private duties. Staffing Manager will check the nurses' notes provided by payroll to make sure all nurses' notes were received. Any notes not received will result in immediate contact with the appropriate RN or LPN. Anyone who doesn't provide notes as expected will be removed from all private duty cases. No exceptions will be made.
An in-person in-service will be conducted for all the home care nurses and nursing assistants to assure compliance with our DOH policies. All new staff doing any DOH Facility cases will have an initial orientation to the protocols in order to alleviate any future deficiencies.
HR Manager will hold ultimate responsibility for ensuring all documentation is received in time. Any deviations from NCS's policies will result in notification of Administrator and immediate in servicing of nursing staff to be brought into compliance.
601.32(b) REQUIREMENT
DUTIES OF THE REGISTERED NURSE
Name - Component - 00
601.32(b) Duties of the Registered
Nurse. The registered nurse:
(i) makes the initial evaluation
visit,
(ii) regularly reevaluates the
patient's nursing needs,
(iii) initiates the plan of treatment
and necessary revisions,
(iv) provides those services
requiring substantial specialized
nursing skill,
(v) initiates appropriate
preventive and rehabilitative nursing
procedures,
(vi) prepares clinical and progress
notes,
(vii) coordinates services, and
(viii) informs the physician and other
personnel of changes in the patient's
condition and needs, counsels the
patient and family in meeting nursing
and related needs, participates in
inservice programs, and supervises and
teaches other nursing personnel.
Observations:
Based on review of agency policy, clinical records (CR), and interview with the agency Administrator, the agency failed to ensure the registered nurse (RN) completed a comprehensive assessment prior to the start of the certification period for seven (7) of seven (7) clinical records (CR) reviewed. (CR #1, 2, 3, 4, 5, 6, and 7).
Findings included:
Review of agency policy " 102.1 B. Skilled Nursing Service Home Health Policy, Duties of the Registered Nurse " on November 20, 2023, at approximately 2:45 P.M. stated, "The registered nurse shall make the initial evaluation visit, regularly reevaluate the patient ' s nursing needs, initiate the plan of treatment and necessary revisions ... "
A review of CR on November 20, 2023, from 10:30 A.M. to 1:00 P.M revealed the following:
CR #1, start of care February 1, 2023. Certification period reviewed: August 1, 2023, through October 31, 2023. Diagnosis: Pain, cellulitis right lower leg. An initial assessment was completed by the RN on February 2, 2023, one (1) day after the start of care. There was no documentation of subsequent comprehensive assessments completed by the RN.
CR #2, start of care March 23, 2023. Certification period reviewed: October 1, 2023, through December 31, 2023. Diagnosis: Post bowel resection, colostomy. An initial assessment was completed by the RN on March 17, 2023. There was no documentation of subsequent comprehensive assessment completed by the RN.
CR #3, start of care May 1, 2023. Certification period reviewed: November 1, 2023, through December 31, 2023. Diagnosis: Inability to void/constipation. An initial comprehensive assessment was completed by the RN on May 1, 2023. There was no documentation of subsequent comprehensive assessment completed by the RN.
CR #6 contained no start of care date and no physician ' s orders. There was no documentation of an initial assessment completed by the RN prior to the start of care.
CR #7, start of care November 2, 2023, contained no physician ' s orders. There was no documentation of an initial assessment completed by the RN prior to the start of care. The Administrator stated that the initial assessment was completed virtually with the licensed practical nurse (LPN).
An interview with the agency Administrator on November 20, 2023, at approximately 3:00 P.M. confirmed the above findings.
Plan of Correction:
NCS will ensure that all the duties of the Registered Nurse are completed and performed appropriately within the scope of nursing laws and within the laws of the Home Health Facility License. The RN (REGISTERED NURSE) will make the initial evaluation visit prior to care, regularly reevaluate the patient's nursing needs; initiates the plan of treatment and necessary revisions, provides those services requiring substantial specialized nursing skill, initiates appropriate preventive and rehabilitative nursing procedures, prepares clinical and progress notes, coordinates services, and informs the physician and other personnel of changes in the patient's condition and needs, counsels the patient and the family in meeting nursing and related needs , participates in in-servicing programs and supervises and teaches other nursing personnel.
All nursing personnel associated with our DOH Facility license will be reeducated on NCS's policies and procedures. This will include the issues from our DOH audit. All areas cited in our DOH 2023 audit will be addressed to all personnel. A DOH handbook will be implemented within a 6-month period addressing all pertinent areas pertaining to all paperwork, code of conduct, and policies and procedures. HR Manager will assist in the construction and maintenance of the anticipated DOH handbook.
All personnel policies and procedures related to RNs, LPNs, will be actively reviewed both with individual clients and with our quarterly reviews. All personnel files and adherence to policies will be reviewed by Administrator and HR Manager
Our policies will be reviewed yearly with our DOH audit.
601.36(a) REQUIREMENT
MAINTENANCE AND CONTENT OF RECORD
Name - Component - 00
601.36(a) Maintenance and Content of
Record. A clinical record is
maintained in accordance with accepted
professional standards and contains:
(i) pertinent past and current
findings,
(ii) plan of treatment,
(iii) appropriate identifying
information,
(iv) name of physician,
(v) drug, dietary, treatment and
activity orders,
(vi) signed and dated clinical
progress notes (clinical notes are
written the day service is rendered
and incorporated no less often than
weekly),
(vii) copies of summary reports sent
to the physician, and
(viii) a discharge summary.
Observations:
Based on a review of clinical records (CR), agency policy, and an interview with the agency Administrator, the agency failed to maintain the CR in accordance with accepted professional standards for seven (7) of seven (7) CR reviewed (CR#1, 2, 3, 4, 5, 6, and 7).
Findings include:
Review of agency policy " 104.1 Clinical Records Maintenance, Retention and Protection Policy " on November 20, 2023, at approximately 2:45 P.M. stated, " A. Maintenance and contents of records: A clinical record containing pertinent past and current findings in accordance with accepted professional standards shall be maintained for every patient receiving home health care services. In addition to the plan of treatment, relating to acceptance of patients, plan of treatment and [medical] supervisor - the record shall contain appropriate identifying information; name of physician; drug and dietary treatment; activity orders; signed and dated clinical notes are written the day service is rendered and incorporated into the clinical record no less often [than] weekly; copies of summary reports sent to the physician; and a discharge summary. "
Review of CR on November 20, 2023, from approximately 10:30 A.M. to 1:00 P.M. revealed the following:
CR #1, start of care February 1, 2023. Certification period reviewed: August 1, 2023, through October 31, 2023. Diagnosis: Pain, cellulitis right lower leg. The " Home Health Certification and Plan of Care " (POC) did not contain medication dosage, route, and frequency, DME (durable medical equipment) and supplies, nutritional requirements, and orders for discipline and treatments that include the discipline of the staff providing services, the frequency and duration of services, and specific orders for care to be provided. The CR did not contain documentation of a 60-day summary for each certification period, a comprehensive assessment by the RN each certification period, comprehensive skilled nursing visit notes with the full date and signature of the staff providing care, and communication notes. The nursing notes contained documentation of the patient receiving wound care on February 1, 2023. There were no orders for wound care and no documentation of the location, stage and measurement of the wound(s). The nurse documented on February 4, 2023, that the patient received Vitamin B. There was no documentation of the medication, dose, route or frequency, and no physician order for the medication. The nurse documented on June 22, 2023, that the patient was taking Amoxicillin 500 mg., 2 capsules every 8 hours. The nurse documented on June 25, 2023, that the patient was taking Methylprednisolone and Azithromycin as prescribed. There was no documentation of the dosage, route, frequency or duration of the medications and no verbal order. The CR did not contain a medication profile listing the medication categories, side effects, interactions, and contraindications.
CR #2, start of care March 23, 2023. Certification period reviewed: October 1, 2023, through December 31, 2023. Diagnosis: Post bowel resection, colostomy. The POC did not contain medication name, dosage, route, and frequency, DME and supplies, functional limitations, activities permitted, and orders for discipline and treatments that include the discipline of the staff providing services, the frequency and duration of services, and specific orders for care to be provided. The CR did not contain documentation of a comprehensive assessment by the RN each certification period, a 60-day summary for each certification period, communication notes, a medication profile, and comprehensive skilled nursing visit notes with the full date and signature of the staff providing care. The skilled nursing visit notes were documented on a typed word document listing the month and all days that the patient was seen for that month, ex. September 4, 9, 14, 19, 24. " Wafer changed without issues " . The entry contained the first initial, last name and discipline. No other information was documented for the visits performed.
CR #3, start of care May 1, 2023. Certification period reviewed: November 1, 2023, through December 31, 2023. Diagnosis: Inability to void/constipation. The POC did not contain medication name, dosage, route, and frequency, catheter type/size, and orders for discipline and treatments that include the discipline of the staff providing services and duration of services, and specific orders for care to be provided. The CR did not contain documentation of a comprehensive assessment by the RN each certification period, a 60-day summary for each certification period, communication notes, a medication profile and there were no skilled nursing visit notes for the certification period.
CR #4, start of care October 25, 2023. Certification period reviewed: No dates provided. Diagnosis: Total knee right. The POC did not list medication name, dosage, route and frequency, DME and Supplies, discipline of the staff providing services, and duration of services. The CR did not contain communication notes and a medication profile.
CR #5, start of care October 24, 2023. Certification period reviewed: October 24, 2023, through November 7, 2023. Diagnosis: Pneumonia, bacterial infection. The POC did not list DME and supplies for PICC (peripherally inserted central catheter/intravenous catheter) line dressing changes, safety measures, the discipline of the staff providing services and the duration of services. The CR did not contain documentation of communication notes, a medication profile, and there were no skilled nursing visit notes for the certification period.
CR #6 contained no start of care date, no physician ' s orders, and no POC. The only documentation present was physician consultation reports from a pulmonologist (respiratory physician), neurologist (brain and nervous system physician) and a nephrologist (kidney physician). There was no documentation of a comprehensive assessment completed by a RN, no communication notes, no medication profile and no skilled nursing visit notes.
CR #7, start of care November 2, 2023, per admission documents. There was no documentation of a POC completed, no physician ' s orders, no comprehensive assessment completed by a RN, no medication profile, and no communication notes.
An interview with the agency Administrator on November 20, 2023, at approximately 3:00 P.M. confirmed the above findings.
Plan of Correction:All clinical records will be maintained in accordance with accepted professional standards and contains the following information; pertinent past and current findings, plan of treatment, appropriate identifying information, name of physician, drug, dietary, treatment and activity orders, signed and dated clinical progress notes written the day service is rendered and incorporated no less often than weekly, copies of summary reports sent to the physician and a discharge summary. NCS will adhere to the standards and ensure compliance via the clinical records review and the quarterly meetings. All clinical records will be reviewed for compliance.
All individual patient files will be reviewed initially by Administrator and HR Manager based on the new policies and procedures implemented since our 2023 DOH Audit. Implementation of weekly nurses note review with time slips; implementation of initial check lists, weekly nurses' notes checklist and quarterly checklists will alleviate non-compliance with the DOH requirements.
NCS will implement all the new procedures listed in all POCs listed in the citations. All efforts will be made to bring NCS into 100% compliance with DOH Facility laws.
HR Manager is responsible for tracking all private cases for compliance. A weekly meeting will be held with HR Manager when we have active HH DOH cases.
Initial Comments:
Based on the findings of an on-site unannounced state re-licensure survey conducted on November 20, 2023, and concluded off-site on November 28, 2023, Nursing Care Services, Inc. was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an on-site unannounced home care agency state re-licensure survey conducted on November 20, 2023, and concluded off-site on November 28, 2023, Nursing Care Services, Inc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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