Initial Comments:
Based on the findings of an unannounced onsite home health agency state re-licensure survey conducted on January 8, 2020, Aurora Home Care, Inc., was found to not be in compliance with the requirements of 28 Pa. Code, Part IV, Health facilities, Subpart G. Chapter 601.
Plan of Correction:
601.22(d) REQUIREMENT
CLINICAL RECORD REVIEW
Name - Component - 00
601.22(d) Clinical Record Review. At
least quarterly, appropriate health
professionals, representing at least
the scope of the program, review a
sample of both active and closed
clinical records to assure that
established policies are followed in
providing services (direct as well as
services under arrangement). There is
a continuing review of clinical
records for each 60-day period that a
patient receives home health services
to determine adequacy of the plan of
treatment and appropriateness of
continuation of care.
Observations:
Based upon review of agency clinical record review for 2019, policy and procedure review, and an interview with the agency Administrator, it was determined the agency failed to ensure quarterly clinical record reviews for Quarter two (2) (April-June), Quarter three (3) (July-September, and Quarter four (4) (October-December) of 2019.
Findings include:
Review of policy "1.20 Clinical Record Maintenance" on January 8, 2020, at approximately 1:00 PM states, "Record Review: Clinical Records are systemically reviewed on a quarterly basis to assess appropriateness and adequacy of care and services...."
Review of agency clinical record review for 2019, on January 8, 2020, at approximately 10:00 AM, revealed no documentation of quarterly clinical record reviews for Quarter two (2) (April-June), Quarter three (3) (July-September), and Quarter four (4) (October-December).
An interview with the agency administrator on January 8, 2020 at approximately 1:30 PM, confirmed the above findings.
Plan of Correction:Administrator and Director of Nursing will be responsible for the Quarterly Record Reviews. All information will be taken from Auroras' system to generate numbers and review of electronic records, notes, etc.. Records will be reviewed by DON an Admin to create a quarterly review that will be submitted to the BOD. Monitoring for completion of these reports will be done by the office manager quarterly and filed appropriately. The first quarter record review will be completed in April.
All reports will detail patient records, goals and interactions and how to improve quality and performance for all disciplines involved in the patients care. DON and Administrator will review all progress notes, clinical interactions, medications and patient outcomes in order to make changes and adjustments to the skilled team. These changes or observations will be review in a meeting with all disciplines involved.
DON and Administrator will complete all 2019 record reviews and have them on file by the end of February.
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 upon clinical record (CR) review, policy and procedure review, and an interview with the agency Administrator, it was determined the agency failed to ensure the physician's plan of treatment to include the physician's counter signature, within seven (7) days of completion, for eight (8) out of ten (10) clinical records reviewed (CR#1, CR#2, CR#5-CR#10).
Findings include:
Review of policy "2.21 Physician's Plan of Treatment" on 1/8/20 at approximately 1:15 PM states " A physician's plan of treatment must be signed by the physician and in the chart within seven (7) days of completion....."
Clinical records were reviewed on 1/8/20 from approximately 11:00 AM-1:00 PM, revealing the following:
CR#1 (Start of Care (SOC): 11/23/2019): Plan of Treatment for certification period 11/23/2019-1/21/2020, contained no physician counter signature, 46 days from the start of the certification period.
CR#2 (SOC: 4/5/2018): Plan of Treatment for certification period 10/23/2019-12/21/2019, contained no physician counter signature, 49 days from the start of the certification period.
CR#5 (SOC: 2/22/2017): Plan of Treatment for certification period 12/09/2019-2/06/2020, contained no physician counter signature, 30 days from the start of the certification period.
CR#6 (SOC: 1/29/2018): Plan of Treatment for certification period 11/20/2019-1/18/2020, contained no physician counter signature, 52 days from the start of the certification period.
CR#7 (SOC: 7/25/2018): Plan of Treatment for certification period 11/17/2019-1/15/2020, contained no physician counter signature, 52 days from the start of the certification period.
CR#8 (SOC: 5/30/2019): Plan of Treatment for certification period 11/26/2019-1/24/2020, contained no physician counter signature, 43 days from the start of the certification period.
CR#9 (SOC: 3/05/2018): Plan of Treatment for certification period 10/25/2019-12/24/2019, contained no physician counter signature, 75 days from the start of the certification period.
CR#10 (SOC: 2/09/2018): Plan of Treatment for certification period 12/01/2019-1/29/2020, contained no physician counter signature, 38 days from the start of the certification period.
An interview with the agency administrator on January 8, 2020 at approximately 1:30 PM, confirmed the above findings.
Plan of Correction:During the CHOW over the course of the last year, Utopia was responsible for all orders/485's until OLTL approved the service location. During this time, orders were submitted to the PCP from a separate program but not sent to PCP's until after the date of the new certification period. Moving forward, as of January 1, Aurora is now active in Well Sky and orders are automatically generated and sent to the PCP directly from the system. The office manager will work diligently to track all orders sent to clients' PCP receive the signed orders within 7 days from the PCP.There will be a fax cover sheet used to track the dates the Orders were sent out and when the orders were received. Once received, the Office Manager will sign them into the program.
The Orders that did not have current signatures had been sent to all the PCP's, they just had not been received back with a signature. Many have been returned, we have resent the Orders that have still not been signed by the PCP with a notice. If orders have not been returned in 7 days, the Business Development Manager will be responsible for hand delivering the Orders and asking for a PCP signature prior to departure.
Initial Comments:
Based on the findings of an unannounced onsite home health agency state re-licensure survey conducted on January 8, 2020, Aurora Home Care, 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 unannounced onsite home health agency state re-licensure survey conducted on January 8, 2020, Aurora Home Care, Inc., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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